1. No category

HEALTHY NORTH CAROLINA 2020:
A Better State of Health
January 2011
(revised March 2011)
The North Carolina Institute of Medicine (NCIOM) is a
nonpolitical source of analysis and advice on important
health issues facing the state. The NCIOM convenes
stakeholders and other interested people from across the
state to study these complex issues and develop workable
solutions to improve health, health care access, and
quality of health care in North Carolina.
The full text of this report is available online at
http://www.nciom.org
North Carolina Institute of Medicine
Keystone Office Park
630 Davis Drive, Suite 100
Morrisville, NC 27560
919.401.6599
Suggested citation
North Carolina Institute of Medicine. Healthy North
Carolina 2020: A Better State of Health. Morrisville, NC:
North Carolina Institute of Medicine; 2011.
North Carolina Institute of Medicine in collaboration
with the Governor’s Task Force for Healthy Carolinians;
Division of Public Health, North Carolina Department of
Health and Human Services (NC DHHS); the Office of
Healthy Carolinians and Health Education, NC DHHS;
and the State Center for Health Statistics, NC DHHS.
Supported by the Kate B. Reynolds Charitable Trust, The
Duke Endowment, and the North Carolina Health and
Wellness Trust Fund.
Any opinion, finding, conclusion or recommendations
expressed in this publication are those of the author(s)
and do not necessarily reflect the view and policies of the
Kate B. Reynolds Charitable Trust, The Duke Endowment,
or the North Carolina Health and Wellness Trust Fund.
Credits
Report design and layout
Angie Dickinson Design, [email protected]
Cover photograph
Rob Landwehrmann
First printing, January 2011
Second printing (revised version), March 2011
HEALTHY NORTH CAROLINA 2020:
A Better State of Health
January 2011
(revised March 2011)
2
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
TABLE OF CONTENTS
Introduction, 2020 Objectives Development Process, and Moving Forward........................................................ 4
Tobacco Use Focus Area and 2020 Objectives........................................................................................................ 8
Physical Activity and Nutrition Focus Area and 2020 Objectives........................................................................ 10
Injury and Violence Focus Area and 2020 Objectives.......................................................................................... 12
Maternal and Infant Health Focus Area and 2020 Objectives............................................................................ 14
Sexually Transmitted Diseases and Unintended Pregnancy Focus Area
and 2020 Objectives......................................................................................................................................... 16
Substance Abuse Focus Area and 2020 Objectives............................................................................................... 18
Mental Health Focus Area and 2020 Objectives.................................................................................................. 20
Oral Health Focus Area and 2020 Objectives...................................................................................................... 22
Environmental Health Focus Area and 2020 Objectives..................................................................................... 24
Infectious Disease and Foodborne Illness Focus Area and 2020 Objectives........................................................ 26
Social Determinants of Health Focus Area and 2020 Objectives........................................................................ 28
Chronic Disease Focus Area and 2020 Objectives............................................................................................... 30
Cross-cutting Focus Area and 2020 Objectives.................................................................................................... 32
Healthy North Carolina 2020 Objectives............................................................................................................ 35
Acknowledgements............................................................................................................................................... 37
Governor’s Task Force for Healthy Carolinians Members................................................................................... 38
Healthy NC 2020 Steering Committee Members................................................................................................ 40
Healthy NC 2020 Subcommittee Members......................................................................................................... 41
References............................................................................................................................................................. 50
HEALTHY NORTH CAROLINA 2020: A Better State of Health
3
HEALTHY NORTH CAROLINA 2020
INTRODUCTION
A
ccording to the World Health Organization, health is defined as a “state of complete physical, mental, and
social well-being, and not merely the absence of disease or infirmity.” North Carolina’s 2020 health objectives
address these components of health with the aim of improving the health status of every North Carolinian. The
case for improving the health of individuals throughout the state is strong. People who are healthier tend to live longer,
use fewer health care services, be generally happier, and be more productive at work.1-3 In addition, the improvement
of population health is an important economic development strategy, because health is a form of human capital and
as such is a significant “input” into our economic system.4 Thus, a healthy population signifies improved quality and
quantity of life for individuals and is an essential contributor to industry and productivity in North Carolina as well.
Over the past dozen years, North Carolina has made noteworthy improvements in many health measures. For
example, North Carolina’s infant mortality rate decreased from 9.3 deaths per 1,000 live births in 1998 to 8.2 deaths
per 1,000 live births in 2008a; the cardiovascular death rate decreased from 363 deaths per 100,000 population in
1999 to 257 deaths per 100,000 population in 2008b; and the percentage of high school youth who use any tobacco
decreased from 38.3% in 1999 to 25.8% in 2009.c Despite
these advancements, these statistics clearly show we still
have a lot of work to do. Furthermore, North Carolina is
currently nationally ranked in the bottom third of many
health measures and 35th in overall health status (with the
best state ranked 1st).5 In fact, over the past two decades,
North Carolina has ranked in, or close to, the bottom third
of all states for many major health indicators, including
but not limited to obesity, smoking, premature death,
infant mortality, and cardiovascular death.6 The state’s
low per capita income is a likely contributing factor to
poor health in North Carolina and thus to the state’s
poor health rankings. Other factors, including health care
access barriers, racial and ethnic disparities, and the high prevalence of unhealthy behaviors in North Carolina, are
also important in explaining North Carolina’s current and historically low health rankings.
People who are healthier
tend to live longer, use
fewer health care services,
be generally happier, and be
more productive at work.
Today in North Carolina, the rate of death due to the misuse of prescription drugs is on a steep rise. One in five adults
smokes, two out of three adults are at an unhealthy weight, and nearly half of all adults have lost permanent teeth
due to tooth decay or gum disease.7-9 In addition, significant disparities—including racial and ethnic, income, and
education level disparities—exist within these and many other public health measures. Disparities must be addressed to
make meaningful improvements in population health. Although these and other public health challenges are daunting,
they are not insurmountable. We know how to improve the health of our population. We can make a difference in
the health of North Carolina’s citizens by implementing multifaceted, evidence-based strategies, including programs
and system and policy changes.
a North Carolina State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. July 9, 2010, and May 13,
2010.
b North Carolina State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. July 9, 2010.
c Tobacco Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. May 20, 2010.
4
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
2020 OBJECTIVES - DEVELOPMENT PROCESS
E
very 10 years since 1990, North Carolina has set decennial health objectives with the goal of making North
Carolina a healthier state. One of the primary aims of this objective-setting process is to mobilize the state to
achieve a common set of health objectives. North Carolina had more than 100 objectives for the year 2010.
Although these objectives formed a comprehensive list of health indicators, the large number of them made it difficult
to focus attention on key objectives that could lead to overall health improvement. Thus, one of the goals of the
Healthy NC 2020 project was to develop a limited number of health objectives. There are 40 objectives within 13
specific focus areas for the year 2020. An objective is what we aim to accomplish, such as a reduction in the percentage
of people with diabetes. Each Healthy NC 2020 objective includes a discrete target that provides a quantifiable way
to measure our success in achieving each Healthy NC 2020 objective, such as a 10% reduction in the percentage of
people with diabetes. Thus, the Healthy NC 2020 objectives provide a common set of health indicators that we, as
a state, can work to improve, while the targets assigned to each objective enable us to monitor our progress, or lack
thereof, toward achieving these common health objectives.
The Healthy NC 2020 objectives were developed over a one-year period on behalf of the Governor’s Task Force for
Healthy Carolinians. (See page 38 for the Governor’s Task Force member list.) The Governor’s Task Force was charged
by the Governor to develop these health objectives. According to the Executive Order, objectives “must be measurable,
include measures to benefit the State’s disparate populations, emphasize individual and community intervention,
emphasize the value of health promotion and disease prevention in our society, and be achievable by the year 2020.”d
Due to the NCIOM’s work in developing the state’s Prevention Action Plane, the Governor’s Task Force asked the
NCIOM to facilitate the development of the 2020 objectives. The NCIOM, in collaboration with the Governor’s Task
Force for Healthy Carolinians; the Division of Public Health, North Carolina Department of Health and Human
Services (NC DHHS); the Office of Healthy Carolinians and Health Education, NC DHHS; and the State Center for
Health Statistics, NC DHHS, helped lead the development of the 2020 objectives. This work was generously supported
by The Duke Endowment, the Kate B. Reynolds Charitable Trust, and the North Carolina Health and Wellness Trust
Fund.
The overall work in developing the 2020 objectives and targets was led by a steering committee that comprised the State
Health Director, Chair of the Governor’s Task Force for Healthy Carolinians, and other public health and prevention
experts. (See page 40 for the steering committee member list.) These experts provided guidance for the development
of the objectives and the selection of targets. Building off the prior work of the NCIOM Prevention Task Force in
developing the Prevention Action Plan, the steering committee identified 13 focus areas for the Healthy NC 2020
objectives. Nine of the 13 Healthy NC 2020 focus areas had been identified in the NCIOM Prevention Action Plan
as major preventable risk factors contributing to the state’s leading causes of death and disability. These nine Healthy
NC 2020 focus areas are tobacco use, nutrition and physical activity, sexually transmitted disease and unintended
pregnancy, substance abuse, environmental risks, injury and violence, infectious disease and foodborne illness, mental
health, and social determinants of health.f The steering committee added four additional focus areas (for a total of
13): maternal and infant health, oral health, chronic disease, and a cross-cutting focus area. These focus areas were
incorporated to capture other significant public health problems as well as summary measures for population health.
In addition to establishing the 13 focus areas, the steering committee identified different methods for establishing
the targets for the 2020 objectives. The goal was to establish targets that were aspirational yet achievable. The steering
committee examined several different target-setting methods for states.10 Among those reviewed were using an
absolute percentage change over time, using a compounded percentage change over time, and using current Healthy
People targets.g The review of these methods helped to inform the specific methods ultimately used in the Healthy
d
e
f
g
North Carolina Executive Order No. 26, Reestablishing the Governor’s Task Force for Healthy Carolinians. October 8, 2009.
For the full Prevention Task Force report: http://www.nciom.org/task-forces-and-projects/?task-force-on-prevention
“Violence” was not part of the Prevention Task Force’s injury study area, but was included for Healthy North Carolina 2020.
The Healthy NC 2020 objectives were developed before the Healthy People 2020 national objectives were finalized, thus these processes were completed independently.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
5
NC 2020 target-setting process. The most commonly used methods to set the Healthy NC 2020 targets were using
the best-performing state in the nation (i.e., the state with the most improvement on a specific health measure over
a specific period), using the best state in the nation (i.e., the state with the best current value on a specific health
measure), maintaining or improving upon North Carolina’s current value or pace of improvement, and reaching the
top percentile of counties in the state.h
The NCIOM convened 11 different subcommittees to develop objectives and targets within each specific focus area. (See
page 41 for a complete list of all subcommittee members.) Each subcommittee comprised subject matter experts charged
with identifying three critical health objectives in a specific focus area. Subcommittees were also asked to identify one
of the three objectives as the key performance indicator for that focus area. These specific indicators were selected for
various reasons; however, in many cases, the key performance indicator was selected because it best represents the
particular focus area. All selected objectives had to meet the criteria of being actionable and measurable. Thus, some
potential objectives were rejected because of a lack of knowledge about how to intervene to make improvements or
because data are not routinely collected to measure the specific health problem, and therefore a baseline measure and
target could not be set. Subcommittees were also asked to help establish the targets for the objectives by using one of
the recommended target-setting methods, whenever possible.i The steering committee developed the objectives and
targets for the chronic disease and cross-cutting focus areas. In addition, the steering committee reviewed the proposed
objectives and targets of the 11 subcommittees to ensure that the objectives, collectively, were balanced in form and
that the level of aspiration was similar throughout all targets. The full set of objectives was then reviewed and ultimately
approved by the Governor’s Task Force for Healthy Carolinians. Additional information about objective development,
target selection, data, and methods is available in the Healthy NC 2020 technical report available at www.nciom.org.
More than 150 North Carolinians—including public health and health professionals, state and local public health
officials, representatives from Healthy Carolinians partnerships and nonprofits, community leaders, academic experts,
and others—contributed their expertise, experience, and time to the development of the Healthy NC 2020 objectives.
The consensus-based approach used in Healthy NC 2020 was vital to the selection of a limited number of robust
objectives and to the establishment of aspirational yet achievable targets. In addition, this process was intended to
generate greater ownership of the objectives. Such ownership is essential to inspiring action.
As part of the Healthy NC 2020 process, regional meetings were held in Pitt, Alamance, and Catawba counties to
provide individuals from across the state with an opportunity to learn about the Healthy NC 2020 project. These
regional meetings also enabled the state to gain valuable information regarding what is needed to help communities
mobilize their efforts and resources to reach the 2020 targets. Nearly 100 people, representing local health departments,
nonprofits, schools, hospitals, communities, Healthy Carolinians partnerships, and other organizations, attended
these meetings.
This report presents the final 2020 objectives and targets for our state. Each of the 13 focus areas is presented in a twopage section. Each section lists the three objectives for the focus area, briefly describes the rationale for the selection
of each objective, shows data on where North Carolina currently is in regards to each objective, and provides the 2020
target.j Where available, state or national data on key health disparities are provided for each objective. A table of
evidence-based strategies concludes each section to provide all North Carolinians with evidence-based actions to take
to achieve the objectives listed within each specific focus area.
h For more detailed information about target-setting methods, refer to the Healthy NC 2020 technical report at www.nciom.org.
i Targets for a few objectives were set in accordance with pre-existing targets set outside the parameters of this project. These are noted in the Healthy NC 2020 technical
report.
j The cross-cutting focus area has four objectives. All other focus areas have three objectives.
6
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
MOVING FORWARD
T
he North Carolina Division of Public Health (DPH), led by the State Health Director, will serve as the lead
agency in the implementation of activities related to Healthy NC 2020. Over the next decade, DPH will use the
objectives as a framework for its efforts to improve health in North Carolina.
The Division is taking a multipronged approach to improving the health of North Carolina’s communities and
reaching the Healthy NC 2020 objectives. First, DPH plans to share the vision for a healthier North Carolina across
the state and to engage diverse sectors, agencies, and organizations in strategic partnerships. As part of this process,
DPH will identify and encourage partners to adopt the 2020 objectives and to implement evidence-based strategies
for population health improvement, such as those in the NCIOM’s Prevention Action Plan. In addition, DPH plans
to establish a mechanism to provide technical assistance and will work diligently to connect communities, health
departments, and hospitals—all of which are at the core of community, and hence state, health. Furthermore, to
measure the state’s progress—or lack thereof—toward the 2020 objectives, DPH will produce annual progress reports.
Reaching the 2020 objectives and targets will be a statewide initiative, and success is possible only through concerted
and coordinated state, regional, and local efforts. The Healthy NC 2020 objectives are intended to provide motivation,
guidance, and focus for public health activities throughout the state. Because of the state’s increased attention on
prevention, we now have three integrated prevention resources to drive our health improvement and disease prevention
efforts. These are the Healthy NC 2020 objectives, the annual progress reports, and the state Prevention Action Plan.
The 2020 objectives are our destination; reaching them will mean that we have significantly improved population
health in the state. The Prevention Action Plan is the state’s roadmap, providing evidence-based strategies to guide the
direction of many of our actions. To complete this analogy, the annual progress reports are the GPS navigation device
that will help us to stay the course and to correct our direction if needed. Together, using these three tools and many
other resources, we can create a better state of health in North Carolina.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
7
HEALTHY NORTH CAROLINA 2020
TOBACCO USE
2020 Objectives
Tobacco use is the leading cause of
preventable death in North Carolina.
Approximately 30% of all cancer deaths
and nearly 90% of lung cancer deaths—
the leading cancer death among men
and women—are caused by smoking.11 In
addition, those who smoke have increased
risks for heart attack and stroke.12 Other
tobacco products also pose health
risks. Smokeless tobacco, for example,
is a known cause of human cancer.13
Nonsmokers also are harmed by tobacco
use through their exposure to secondhand
smoke, which contains more than 7,000
chemicals. About 70 of these can cause
cancer, and hundreds are toxic.14 Tobacco
use is a costly problem in the state leading
to medical expenditures of $2.4 billion
(in 2004), including $769 million to
Medicaid.15 In 2006, secondhand smoke
exposure alone led to excess medical costs
of approximately $293.3 million (in 2009
dollars).16
OBJECTIVE 1: DECREASE THE PERCENTAGE OF ADULTS
WHO ARE CURRENT SMOKERS
(KEY PERFORMANCE INDICATOR)
Rationale for selection: An estimated 13,000 North Carolinians
aged 35 years or older died from a smoking-related cause each
year during 2005-2009. North Carolina has the 14th highest
smoking prevalence in the nation. Although overall smoking rates
among adults in the state have dropped in the past decade, North
Carolina still lags behind the national average.17
CURRENT (2009)18
2020 TARGET
20.3%
13.0%
OBJECTIVE 2: DECREASE THE PERCENTAGE OF HIGH
SCHOOL STUDENTS REPORTING CURRENT USE OF ANY
TOBACCO PRODUCTk
Rationale for selection: Preventing youth from using tobacco is
important to reducing the overall smoking rate. Most adults who
use tobacco began smoking before the age of 18 years, with the
average age of initiation between 12 and 14 years.19 Smokers
typically become addicted to nicotine before they reach age 20.20
Youth who use other tobacco products (OTPs) are more likely to
smoke.13
CURRENT (2009)l
2020 TARGET
25.8%
15.0%
OBJECTIVE 3: DECREASE THE PERCENTAGE OF PEOPLE
EXPOSED TO SECONDHAND SMOKE IN THE WORKPLACE IN
THE PAST SEVEN DAYSm
Rationale for selection: Secondhand smoke exposure causes heart
disease and lung cancer. In fact, the risk to nonsmokers for heart
disease increases by 25%-30% and for lung cancer by 20%30%.21 There is no safe level of exposure to secondhand smoke,
and exposure for even a short duration is harmful to health.22
CURRENT (2008)23
2020 TARGET
14.6%
0%
k “Any tobacco product” includes cigarettes, cigars, smokeless tobacco, pipes, or bidis.
l Tobacco Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. May 20, 2010.
m Includes only individuals employed for wages or self-employed.
8
North Carolina Institute of Medicine
Disparities in Tobacco Use
Smoking among adults: Individuals with less education and those with lower incomes are more likely to smoke. People
with less than a high school education are three times as likely to smoke as college graduates (30.9% versus 10.1% in
2009), and those with higher incomes are less likely to smoke (10.4% among those making $75,000 or more versus
29.4% among those making less than $15,000 in 2009). The smoking prevalence among American Indians of 41.6%
is twice that of other racial/ethnic groups (2009).24 In addition, particular subsets of the population are more likely to
smoke, for example, individuals with certain lifetime mental illnesses and those with serious psychological distress.25
Tobacco use among high school students: Males are more likely to use tobacco products than females (30.8% versus
20.2% in 2009). Use increases as age and grade increase. Students in the 12th grade are nearly twice as likely to report
use than students in the ninth grade (35.9% versus 18.2% in 2009). White students report the highest use among
racial/ethnic groups (28.3% for whites versus 21.8% for African American and 18.5% for Hispanics in 2009).n,o
Secondhand smoke (SHS) exposure in the workplace: Males are approximately two times as likely to be exposed to SHS
at the workplace than women (18.7% versus 9.5% in 2008). Individuals with lower incomes are more likely to report
exposure. For example, 29.4% of those earning less than $15,000 report exposure versus 7.9% earning $75,000 or
more (2008). Exposure is also inversely related to education; individuals with more education are more likely to not
be exposed (2008).23
Strategies to Prevent and Reduce Tobacco Use
Level of the
Socioecological Model
Strategies
Individual
Be tobacco free.26
Family/Home
Maintain a tobacco-free home.27
Clinical
Offer comprehensive cessation services (counseling and medication) to help smokers and other
tobacco users quit28; stay up-to-date on evidence-based clinical preventive screenings, counseling, and
treatment guidelines.29
Schools and Child Care
Enforce tobacco-free school laws30; enforce smokefree child care facility rulesp; implement evidencebased healthful living curricula in schools.17,31
Worksites
Institute a worksite wellness program using interventions accompanied by incentives for cessation32;
implement smoking bans or restrictions in worksites.33
Insurers
Provide coverage with no cost sharing for tobacco use screening and counseling for adolescents;
and for screening, cessation counseling, and appropriate cessation interventions, including cessation
medications, for adults; and for screening and pregnancy-tailored counseling for pregnant women34,q;
provide coverage for drug use assessment for individuals aged 11-21 years.35
Community
Expand smoking bans or restrictions in community spaces36; encourage mass media campaigns
(coupled with local laws directed at tobacco retailers)36,37; support school-based and school-linked
health services.31
Public Policies
Expand tobacco-free policies to all workplaces and in community establishments36; increase the
tobacco tax38; provide tax incentives to encourage worksite wellness programs17; fund and implement
a Comprehensive Tobacco Control Program17; provide funding to support school-based and schoollinked health services and achieve a statewide ratio of 1 school nurse for every 750 middle and high
school students.31
n Tobacco Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. December 1, 2010.
o In this report, white and African American are racial categories and do not distinguish ethnicity unless otherwise noted. African American includes African Americans and
other blacks living in the United States. Hispanic is an ethnic category and does not distinguish race.
p 10A NCAC § 09.0604(g)
q Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
9
HEALTHY NORTH CAROLINA 2020
PHYSICAL ACTIVITY AND NUTRITION
2020 Objectives
Overweight and obesity pose significant
health concerns for both children
and adults. Excess weight increases an
individual’s risk of developing type 2
diabetes, high blood pressure, heart
disease, certain cancers, and stroke.39
For the first time in two centuries, the
life expectancy of children in the United
States is predicted to be lower than that
of their parents. The root cause of this
phenomenon is the increase in obesity.40
Increased physical activity and improved
nutrition are among the many factors that
can help individuals reach and maintain a
healthy weight.
OBJECTIVE 1: INCREASE THE PERCENTAGE OF HIGH
SCHOOL STUDENTS WHO ARE NEITHER OVERWEIGHT NOR
OBESEr,s
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Overweight and obese youth are more at
risk to be overweight or obese adults.41 They are also more likely to
have high cholesterol and high blood pressure—both risk factors
for cardiovascular disease. The percentage of youth with type 2
diabetes has increased significantly with the rise in overweight and
obesity.42
CURRENT (2009)43
2020 TARGET
72.0%
79.2%
OBJECTIVE 2: INCREASE THE PERCENTAGE OF ADULTS
GETTING THE RECOMMENDED AMOUNT OF PHYSICAL
ACTIVITYt
Rationale for selection: Physical activity is an important factor
affecting overall health as well as body weight. Regular physical
activity reduces the risk of heart disease, stroke, hypertension,
and type 2 diabetes.41 Regular physical activity also reduces risk
for certain cancers, strengthens bones and muscles, and improves
mental health.44
CURRENT (2009)45
2020 TARGET
46.4%
60.6%
OBJECTIVE 3: INCREASE THE PERCENTAGE OF ADULTS
WHO CONSUME FIVE OR MORE SERVINGS OF FRUITS AND
VEGETABLES PER DAY
Rationale for selection: Good nutrition is essential to good health
and healthy weight. Fruits and vegetables are nutritious foods that
have been shown to guard against many chronic diseases, including
cardiovascular disease, type 2 diabetes, and some cancers.46
r
s
t
10
CURRENT (2009)47
2020 TARGET
20.6%
29.3%
The percentage of students who are neither overweight nor obese equals 100% minus the total percentage of students who are overweight or obese.
The cross-cutting focus area contains an objective for adult overweight/obesity.
Recommended physical activity is defined here as at least 30 minutes of moderate physical activity five or more days per week or vigorous physical activity for at least 20
minutes three or more days per week.
North Carolina Institute of Medicine
Disparities in Physical Activity and Nutrition
Overweight/obesity among high school students: Non-Hispanic white high school students are more likely to not be
overweight or obese than non-Hispanic African American and Hispanic students (77.4% versus 62.2% and 71.8%
in 2009). In addition, younger high school students are generally more likely to not be overweight or obese (2009).48
Physical activity levels among adults: Males are more likely than females to get the recommended amount of physical
activity (51.1% versus 41.9% in 2009). Income and education are also related to physical activity levels. For example,
individuals with the least income are the least likely to get the recommended level. The recommended level is achieved
by 33.9% among individuals making $15,000 or less and by 54% among those making $75,000 or more (2009).49
Fruit and vegetable consumption among adults: Increasing education and income are both positively associated with fruit
and vegetable intake. College graduates are more than 1.5 times as likely to eat five fruits and vegetables a day as those
with a high school diploma or GED (2009). Similarly, individuals earning more than $75,000 are more than 1.5 times
as likely to eat five or more fruits and vegetables a day than those earning less than $15,000 (2009).50
Strategies to Prevent and Reduce Obesity by Promoting Healthy Eating
and Physical Activity
Level of the
Socioecological Model
Strategies
Individual
Eat more fruits and vegetables; increase physical activity level.51
Family/Home
Serve fruits and vegetables with meals51; reduce screen time at home.52
Clinical
Offer obesity screening for children aged more than 6 years and for adults, and offer counseling and
behavioral interventions for those identified as obese34; expand childhood obesity prevention initiatives
for children51; stay up-to-date on evidence-based clinical preventive screening, counseling, and
treatment guidelines.
Schools and Child Care
Offer high-quality physical education and healthy foods and beverages17,51,53; implement evidencebased healthful living curricula in schools17,31; expand physical activity and healthy eating in afterschool and child care programs17,53; support joint use of recreational facilities.17
Worksites
Institute worksite wellness programs and promote healthy foods and physical activity54; assess health
risks and offer feedback and intervention support to employees.55
Insurers
Offer coverage at no cost sharing for obesity screening for children aged more than 6 years and adults
and for counseling and behavioral interventions for those identified as obese.34,u
Community
Implement Eat Smart, Move More community-wide obesity prevention strategies17; promote menu
labeling in restaurants53; build active living communities51; support joint use of recreational facilities17;
support school-based and school-linked health services.31
Public Policies
Require schools to offer high-quality physical education and healthy foods and beverages17,51,53; require
schools to implement evidence-based healthful living curricula in schools17,31; fund Eat Smart, Move
More community-wide obesity prevention plans17; provide community grants to promote physical
activity and healthy eating17,51; support community efforts to build active living communities51; provide
tax incentives to encourage comprehensive worksite wellness programs17; and provide funding to
support school-based and school-linked health services and achieve a statewide ratio of 1 school nurse
for every 750 middle and high school students.31
u Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
11
HEALTHY NORTH CAROLINA 2020
INJURY AND VIOLENCE
2020 Objectives
Injury is a leading cause of death and
disability in North Carolina. In 2007,
injury in North Carolina resulted in more
than 154,000 hospitalizations, 812,000
emergency department visits, and 6,200
deaths. Injury is the leading cause of
death among people aged 1 to 49 years,
and homicide in particular is the second
leading cause of death for people aged 15
to 24 years. The annual cost of injury to
the state is greater than $27 billion.56
OBJECTIVE 1: REDUCE THE UNINTENTIONAL POISONING
MORTALITY RATE (PER 100,000 POPULATION)
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Most unintentional poisoning deaths
occur because of the misuse of prescription narcotics.56 North
Carolina has experienced dramatic increases in the percentage
of unintentional deaths due to poisoning in the past three
decades, including a 139% increase from 2000 to 2007.v In 2007,
unintentional poisoning was the second leading cause of injury
deaths in the state.56
CURRENT (2008)w
2020 TARGET
11.0
9.9
OBJECTIVE 2: REDUCE THE UNINTENTIONAL FALLS
MORTALITY RATE (PER 100,000 POPULATION)
Rationale for selection: In 2007, falls yielded the third leading cause
of unintentional injury deaths in the state and the leading cause
of injury-related hospitalization and emergency department visits.
More than 75% of falls occur in adults aged more than 65 years.
Fall-related deaths are expected to increase as the population in
the state increases and ages.56
CURRENT (2008)x
2020 TARGET
8.1 5.3
OBJECTIVE 3: REDUCE THE HOMICIDE RATE (PER 100,000
POPULATION)
Rationale for selection: Homicide is a completely preventable cause
of death. Arguments, abuse or conflict, intimate partner violence,
drug involvement, and serious crimes are the most common event
circumstances for homicides.57
v
w
x
y
12
CURRENT (2008)y
2020 TARGET
7.5 6.7
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. December 21, 2010.
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. September 3, 2010.
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. September 3, 2010.
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. September 3, 2010.
North Carolina Institute of Medicine
Disparities in Injury and Violence
Unintentional poisoning mortality: Men are twice as likely to die from unintentional poisoning as women; the rate for
men is 14.8 deaths per 100,000 population, whereas for women it is 7.4 deaths per 100,000 population (2008). Also,
American Indians and whites are more likely to die from this cause than other racial/ethnic groups, with rates of 13.3
and 13.2 deaths per 100,000 population, respectively, compared with the overall state rate of 11.0 deaths per 100,000
population (2008). The risk for death due to poisoning is greatest for individuals aged 25-54 years (2008).z
Falls mortality: Whites are at greatest risk of a fall-related death (9.7 deaths per 100,000 population versus 3.1 deaths
per 100,000 population for African Americans in 2008). Furthermore, the risk of death from falls increases with age;
individuals aged at least 65 years are most likely to die from a fall (2008).aa
Homicide: Of all racial/ethnic groups, African Americans and American Indians are most at risk of homicide, with
rates of 15.9 and 20.8 deaths per 100,000 population, respectively, versus 4.4 deaths per 100,000 population for
whites (2008). The highest homicide rates are among individuals aged 15-34 years (2008).bb
Strategies to Prevent and Reduce Injury and Violence
Level of the
Socioecological Model
z
aa
bb
cc
Strategies
Individual
Practice common sense safety; older adults should exercise regularly and reduce tripping hazards58;
follow directions on medication/chemical labels59; be safe at work; take breaks to stretch your muscles;
get enough sleep.60
Family/Home
Reduce potential hazards in the home; supervise children at home and on the playground61; store
medicines and chemicals in locked cabinets.62
Clinical
Offer counseling to prevent injuries63; learn about evidence-based strategies to prevent and to reduce
injuries; collect and report injury data; cross-train home-visit staff to assist the elderly, individuals with
disabilities and their caregivers, and low-income families with fall prevention measures.63
Schools and Child Care
Establish a social environment that promotes safety and prevents unintentional injuries, violence, and
suicide64,65; maintain safe playgrounds, school grounds, and school buses; provide health, counseling,
psychological, and social services to meet the needs of students65; implement evidence-based healthful
living curricula in schools.17,31
Worksites
Meet Occupational Safety and Health Act requirements to provide a workplace that is “free from
recognized hazards that are causing or are likely to cause death or serious physical harm.”cc
Insurers
Provide coverage for screening and anticipatory guidance for children and adolescents to reduce injury
and violence.35
Community
Support adoption of healthy, safe, accessible, affordable, and environmentally friendly homes63;
inform older adults, people with disabilities, and housing and health care professionals about eligibility
and coverage in existing home modification services and products (e.g., Medicare and Medicaid)63;
promote a community of violence prevention66; support school-based and school-linked health
services.31
Public Policies
Enforce housing code requirements to prevent injury63; fund injury surveillance and intervention17;
create a statewide task force to prevent injury and violence17; fund injury prevention training for health
professionals17; enforce housing and sanitary code requirements63; promote policies that ensure gender
and social equity to prevent violence66; provide funding to support school-based and school-linked
health services and achieve a statewide ratio of 1 school nurse for every 750 middle and high school
students.31
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. December 2, 2010.
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. December 2, 2010.
Injury Prevention and Control Branch, North Carolina Department of Health and Human Services. Written (email) communication. December 2, 2010.
29 USC §654.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
13
HEALTHY NORTH CAROLINA 2020
MATERNAL AND INFANT HEALTH
2020 Objectives
Maternal health is an important predictor
of newborn health and well-being, and
addressing women’s health is essential
to improving birth outcomes. Many
factors affect women’s health, including
individual health behaviors, access to
appropriate care, and socioeconomic
factors. Focusing on the health of a woman
before and during her pregnancy is essential
to the reduction of poor birth outcomes
such as low birthweight, pre-term birth,
and infant death.67,68
OBJECTIVE 1: REDUCE THE INFANT MORTALITY RACIAL
DISPARITY BETWEEN WHITES AND AFRICAN AMERICANS
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Infant mortality refers to the death of a
baby in its first year of life. Racial and ethnic disparities in infant
mortality in North Carolina persist. The death rate of African
American babies is nearly 2.5 times the death rate of white babies.
Of all infant mortality racial/ethnic disparities in the state, this
disparity is the greatest.69
CURRENT (2008)dd
2020 TARGET
2.45
1.92
OBJECTIVE 2: REDUCE THE INFANT MORTALITY RATE (PER
1,000 LIVE BIRTHS)
Rationale for selection: Over 1,000 babies (under age 1) died
in 2009 in North Carolina.70 The most prevalent causes of infant
mortality are birth defects, prematurity, low birth weight, and
Sudden Infant Death Syndrome (SIDS).71
CURRENT (2008)ee
2020 TARGET
8.2 6.3
OBJECTIVE 3: REDUCE THE PERCENTAGE OF WOMEN WHO
SMOKE DURING PREGNANCY
Rationale for selection: Smoking during pregnancy is associated
with multiple adverse birth outcomes, including low-birth-weight
babies and pre-term deliveries.72 Women who smoke during
pregnancy are more likely to have a baby who is premature, who
has a low birth weight, or who dies because of SIDS.73
CURRENT (2008)74
2020 TARGET
10.4%
6.8%
dd State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. May 13, 2010.
ee State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. May 13, 2010.
14
North Carolina Institute of Medicine
Disparities in Maternal and Infant Health
Infant mortality: Whites have the lowest infant mortality rate (6.0 deaths per 1,000 live births), versus a rate of
13.5 deaths per 1,000 live births for all minorities (2008).75 As described in the objective, the greatest racial/ethnic
disparity exists between whites and African Americans.ff
Smoking during pregnancy: Education, age, and race/ethnicity are associated with maternal smoking. White, nonHispanic women with less education and who are younger are more likely to smoke during pregnancy, as are American
Indian women.76
Strategies to Improve Maternal and Infant Health
Level of the
Socioecological Model
ff
gg
hh
ii
Strategies
Individual
Plan your pregnancy77; enter into pregnancy healthy78; be tobacco free during pregnancy79; access preand postnatal care80,81; breastfeed your baby82; space apart pregnancies by 2 to 3 years.83
Family/Home
Maintain a tobacco-free home27; put children on their backs to sleep79; do not use soft bedding.79
Clinical
Promote reproductive life planning84; screen all pregnant women for tobacco use and provide
counseling34; screen for postpartum depression34; encourage women in good health to breastfeed.82
Schools and Child Care
Put children on their backs to sleep79; do not use soft bedding.79
Worksites
Encourage employers to provide time and space for their employees to breastfeed.82,gg
Insurers
Provide coverage with no copays for breastfeeding and smoking cessation counseling for pregnant
women.34,82,hh,ii Community
Expand availability of family planning services and community-based pregnancy prevention programs
for low-income families, such as the Nurse Family Partnership17,85; support the “Back to Sleep”
campaign79; offer age-appropriate education to student and parent groups.82
Public Policies
Create policies that encourage formal training on breastfeeding and lactation in medical schools and
residency programs82; fund expansion of family planning services and community-based pregnancy
prevention programs for low-income families, such as the Nurse Family Partnership.17,85
State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. May 13, 2010.
Patient Protection and Affordable Care Act, Pub L No. 111-148, §4207.
Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
15
HEALTHY NORTH CAROLINA 2020
SEXUALLY TRANSMITTED DISEASE AND
UNINTENDED PREGNANCY
2020 Objectives
Sexually transmitted diseases (STDs),
including
human
immunodeficiency
virus (HIV) infection, and unintended
pregnancy affect tens of thousands of
North Carolinians every year. These
preventable conditions can lead to reduced
quality of life as well as premature death
and disability and result in millions of
dollars in preventable health expenditures
annually.17 As with many diseases and
health conditions, the burden of sexually
transmitted diseases and unintended
pregnancy falls disproportionately on
disadvantaged populations, young people,
and minorities.86-88
OBJECTIVE 1: DECREASE THE PERCENTAGE OF
PREGNANCIES THAT ARE UNINTENDED
(KEY PERFORMANCE INDICATOR)
Rationale for selection: The term unintended pregnancy refers
to a pregnancy that was mistimed or unwanted at the time of
conception. Nearly half of all pregnancies in North Carolina are
unintended, which is associated with delayed entry into prenatal
care as well as low-birth-weight babies and poor maternal
nutrition.89
CURRENT (2007)90
2020 TARGET
39.8%
30.9%
OBJECTIVE 2: REDUCE THE PERCENTAGE OF POSITIVE
RESULTS AMONG INDIVIDUALS AGED 15-24 YEARS TESTED
FOR CHLAMYDIA
Rationale for selection: Chlamydia is the most prevalent reportable
STD in North Carolina. This infection can cause infertility and pelvic
inflammatory disease (PID) in females. In 2008, individuals under
the age of 30 years accounted for approximately 85% of new
chlamydia cases across the state.86
CURRENT (2009)jj
2020 TARGET
9.7%
8.7%
OBJECTIVE 3: REDUCE THE RATE OF NEW HIV INFECTION
DIAGNOSES (PER 100,000 POPULATION)kk
Rationale for selection: An estimated 35,000 North Carolinians
have HIV/AIDS (including those who are unaware of their status).
Furthermore, HIV/AIDS was the seventh leading cause of death
among 25- to 44-year-olds in 2007.86
CURRENT (2008)91
2020 TARGET
24.7
22.2
jj Communicable Disease Branch, North Carolina Department of Health and Human Services. Written (email) communication. July 19, 2010.
kk Diagnosis rate includes children, adolescents, and adults.
16
North Carolina Institute of Medicine
Disparities in Sexually Transmitted Disease and Unintended Pregnancy
Unintended pregnancy: Education, income, race, and marital status are all associated with unintended pregnancy.
Women with less than a high school education are 1.6 times as likely to have an unintended pregnancy than women
with greater than a high school education, and women making less than $15,000 are 3.4 times as likely as women
making $50,000 or more (2007). In addition, African American women are 1.7 times as likely as white women to
report their pregnancy was unintended (59.6% versus 33.9% in 2007). Unmarried women, as well as women on
Medicaid, are more likely than their counterparts to report unintended pregnancy (2007).92
Chlamydia: The highest rates of chlamydia are found among females aged 15-24 years and males aged 20-24 years
(2008). Non-Hispanic African American females are at particular risk for infection, with infection rates seven times that
of non-Hispanic white females (2008). These disparities can partially be explained by screening and reporting bias. Most
cases are among women because they are tested more frequently. In addition, data are biased toward public clinics.86
HIV: New HIV infections, pediatric cases, AIDS cases, and AIDS-related death place a great burden on non-Hispanic
African Americans in North Carolina. Nearly two-thirds (64%) of all new adult/adolescent HIV diagnoses are among
non-Hispanic African Americans, with a rate of 79.5 new diagnoses per 100,000 population (2008). The second highest
rate is among Hispanics (35.8 new diagnoses per 100,000 population in 2008). These two rates are 8.3 times higher and
3.7 times higher, respectively, than the non-Hispanic white diagnosis rate of 9.6 new cases per 100,000 population (2008).
According to 2008 data, males in all racial/ethnic categories are more likely than women to receive a diagnosis of HIV
infection. Injecting drug users and men who have sex with men also are at increased risk for contracting HIV (2008).86
Strategies to Prevent and Reduce Sexually Transmitted Disease and
Unintended Pregnancy
Level of the
Socioecological Model
Strategies
Individual
Use protection to prevent STDs and unintended pregnancy; get screened for human immunodeficiency
virus (HIV) if at increased risk for HIV infection (or if pregnant)93; get the HPV vaccine if you are a
female aged 11-26 years.94
Family/Home
Talk to your children about the consequences of risky sexual behavior; encourage females aged 11-26
years to get the HPV vaccine.94
Clinical
Provide screening, counseling, and treatment of STDs/HIV infection as recommended by the
US Preventive Services Task Force93; screen women younger than 25 years and others at risk for
chlamydia95; use provider-referral partner notification to identify people with HIV96; counsel injecting
drug users (IDUs) who are at increased risk for HIV97; offer HPV vaccine to females aged 11-26 years94
and to males aged 9-26 years98; provide interventions for men who have sex with men.99
Schools and Child Care
Ensure that all students receive comprehensive sexuality education17,100; implement evidence-based
healthful living curricula in schools17,31; deliver group-based comprehensive risk reduction (CRR) to
adolescents to promote behaviors that prevent or reduce the risk of pregnancy, HIV, and other STDs.101
Insurers
Provide coverage for STD/HIV screening and counseling for sexually active adolescents and highrisk adults; provide screening for chlamydia among women younger than 25 years and for others at
increased risk, with no cost sharing.34,ll
Community
Expand availability of family planning services and community-based pregnancy prevention programs,
such as the Nurse Family Partnership17,85; educate youth about the importance of sexual health100;
support school-based and school-linked health services31; provide youth development-focused behavioral
interventions coordinated with community service components102; create sterile needle exchange
programs for IDUs97; provide group and community-level interventions for men who have sex with men.99
Public Policies
Pass policies that ensure comprehensive sexuality education for all students17,100; provide funding to
support school-based and school-linked health services and achieve a statewide ratio of 1 school nurse
for every 750 middle and high school students31; fund community education campaigns to increase
awareness of sexual health100; fund expansion of family planning services and community-based
pregnancy prevention programs for low-income families, such as the Nurse Family Partnership.17,85
ll Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
17
HEALTHY NORTH CAROLINA 2020
SUBSTANCE ABUSE
2020 Objectives
Substance use and abuse are major
contributors to death and disability in
North Carolina.17 Addiction to drugs
or alcohol is a chronic health problem,
and people who suffer from abuse or
dependence are at risk for premature death,
comorbid health conditions, injuries,
and disability. Therefore, prevention of
misuse and abuse of substances is critical.
Furthermore, substance abuse has adverse
consequences for families, communities,
and society, contributing to family
upheaval, the state’s crime rate, and motor
vehicle fatalities.103
OBJECTIVE 1: REDUCE THE PERCENTAGE OF HIGH SCHOOL
STUDENTS WHO HAD ALCOHOL ON ONE OR MORE OF THE
PAST 30 DAYS
(KEY PERFORMANCE INDICATOR)
Rationale for selection: One in three high school students in North
Carolina reports having at least one drink of alcohol in the past 30
days.104 Youth are more likely to drink in larger quantities and to
engage in binge drinking than adults. Youth are also particularly
susceptible to the influence of alcohol because it affects the
developing brain.105 Furthermore, early onset of drinking increases
the risk of alcohol addiction.106
CURRENT (2009)107
2020 TARGET
35.0%
26.4%
OBJECTIVE 2: REDUCE THE PERCENTAGE OF TRAFFIC
CRASHES THAT ARE ALCOHOL-RELATED
Rationale for selection: Motor vehicle injury is the leading cause of
injury death in North Carolina.108 In 2008, one of every 18 crashes
involved alcohol, and one of every 3 alcohol-related crashes was
fatal.109
CURRENT (2008)110
2020 TARGET
5.7%
4.7%
OBJECTIVE 3: REDUCE THE PERCENTAGE OF INDIVIDUALS
AGED 12 YEARS AND OLDER REPORTING ANY ILLICIT DRUG
USE IN THE PAST 30 DAYS
Rationale for selection: Illicit drugs include marijuana/hashish,
cocaine (including crack), heroin, hallucinogens, inhalants,
or prescription-type psychotherapeutics used for nonmedical
purposes.111 Because addiction is a disease that often begins in
childhood and adolescence, it is particularly important to prevent
and to reduce use among youth.103
18
CURRENT (2007-08)112
2020 TARGET
7.8%
6.6%
North Carolina Institute of Medicine
Disparities in Substance Abuse
Youth alcohol use: Age and grade are positively associated with alcohol use. Students in grades 10-12 are approximately
1.5 to 1.8 times as likely to use alcohol as ninth grade students (2009). Similarly, 16- and 17-year-olds are approximately
1.5 times as likely to report drinking in the past 30 days than students 15 years and younger (2009).113
Alcohol-related traffic crashes: Young people—at all levels of blood alcohol concentration—are at increased risk of being
involved in a crash. Nationally in 2008, approximately one in three fatal crashes involving alcohol blood levels of
0.08% or greater involved young adults aged 21-24 years.114
Illicit drug use: Young adults aged 18-25 years are more likely to report illicit drug use than people of other ages (19.5%
versus 9.8% for those aged 12-17 and 5.6% for those aged 26 and older in 2007-2008).112
Strategies to Prevent and Reduce Substance Abuse
Level of the
Socioecological Model
Strategies
Individual
Be free from substance abuse, and seek help for substance abuse problems115,116; use prescription
medication as prescribed and be aware of prescription drug misuse.117
Family/Home
Talk to your children about the dangers of substance use and help family members with substance use
problems get into treatment118,119; parents should serve as positive role models for children by neither
drinking excessively nor using drugs.17,118,119
Clinical
Offer screening and behavioral counseling interventions to reduce alcohol misuse by adults and
pregnant women34; offer drug and alcohol use assessments for adolescents aged 11-21 years.35
Schools and Child Care
Implement evidenced-based substance abuse prevention programs118,120; implement evidence-based
healthful living curricula in schools17,31; establish, review, and enforce rules about underage drinking
with sufficient consequences.118
Worksites
Offer employee assistance programs that include screening and referrals for substance use121; combat
stigma against seeking help for substance abuse121; offer facts on the harmful health effects of
excessive use of alcohol.121
Insurers
Offer coverage for substance abuse services in parity with other services103; cover screening and
behavioral counseling interventions to reduce alcohol and drug misuse by adolescents with no cost
sharing35,122; cover screening and behavioral counseling interventions to reduce alcohol misuse by
adults and pregnant women with no cost sharing.34,123,mm
Community
Invest in alcohol-free youth programs and volunteer opportunities118; widely publicize alcohol laws118;
develop and implement a comprehensive substance abuse prevention plan17; support school-based
and school-linked health services.31
Public Policies
Increase the tax on beer and wine17,124; enforce legal liability of places where alcohol is sold for
actions/harms caused by customers125; expand funding to support regular, well-publicized sobriety
checkpoints17; enforce blood alcohol content and “zero tolerance” laws for drunk driving126; require
appropriate therapeutic interventions for parents with substance use disorders who are before courts
because children are at heightened risk for underage drinking and drug use118; develop comprehensive
systems of care that include prevention, treatment, and recovery supports103; provide funding to
support school-based and school-linked health services and achieve a statewide ratio of 1 school nurse
for every 750 middle and high school students.31
mm Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
19
HEALTHY NORTH CAROLINA 2020
MENTAL HEALTH
2020 Objectives
Mental health, an integral component of
individual health, is important throughout
the lifespan. Individuals with poor
mental health may have difficulties with
interpersonal relationships, productivity in
school or the workplace, and their overall
sense of well-being.127 Depression is linked
to lower productivity in the workplace, is
a leading cause of suicide, and has been
associated with increased use of health
care services.17
OBJECTIVE 1: REDUCE THE SUICIDE RATE (PER 100,000
POPULATION)
(KEY PERFORMANCE INDICATOR)
Rationale for selection: In 2008, suicide was the fourth leading
cause of injury death in North Carolina and was among the top five
leading causes of injury death for North Carolinians aged 10 years
and older.108 Depression, which is the second leading cause of life
lived with a disability in the state, is a leading cause of suicide.17,128
CURRENT (2008)nn
2020 TARGET
12.4
8.3
OBJECTIVE 2: DECREASE THE AVERAGE NUMBER OF POOR
MENTAL HEALTH DAYS AMONG ADULTS IN THE PAST 30
DAYS
Rationale for selection: The number of poor mental health days
within the past 30 days is used as one measurement of a person’s
health-related quality of life. Poor mental health includes stress,
depression, and other emotional problems and can prevent a
person from successfully engaging in daily activities, such as selfcare, school, work, and recreation.127
CURRENT (2008)129
2020 TARGET
3.4
2.8
OBJECTIVE 3: REDUCE THE RATE OF MENTAL HEALTHRELATED VISITS TO EMERGENCY DEPARTMENTS (PER 10,000
POPULATION)oo
Rationale for selection: Although the emergency department
setting may be appropriate in crisis situations, it is not the ideal
setting in which to address mental health problems. However,
the use of emergency departments for mental health care is
growing.130 Individuals with mental health needs are best treated
with regular and comprehensive care, such as that offered through
a coordinated system of care.
nn
oo
pp
20
CURRENT (2008)pp
2020 TARGET
92.0
82.8
State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. July 9, 2010.
This objective refers to child and adult visits in which a mental health diagnosis was the primary diagnosis.
The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). Written (email) communication. December 23, 2010.
The NC Public Health Data Group and NC DETECT do not take responsibility for the scientific validity or accuracy of methodology, results, statistical analyses, or
conclusions presented.
North Carolina Institute of Medicine
Disparities in Mental Health
Suicide: Men are almost four times as likely to commit suicide as women (19.9 versus 5.6 suicides per 100,000
population in 2008). Whites have higher suicide rates than African Americans and individuals of other racial/ethnic
groups. Suicide rates in the western part of the state are higher than in the Piedmont or eastern parts of the state (17.6
versus 11.4 and 12.2 suicides per 100,000 population, respectively, in 2008).qq
Poor mental health days: Females report more poor mental health days in the previous 30 days than men (4.0 versus 2.8
days, in 2008). Hispanics report having the fewest poor mental health days (2.2 days), compared with non-Hispanic
whites (3.4 days) and non-Hispanic African Americans (3.8 days), whereas American Indians report the most poor
mental health days (5.8 days) (2008).131
Strategies to Improve Mental Health
Level of the
Socioecological Model
Strategies
Individual
Seek help for mental health problems132; older adults aged 60 years and older should have depression
care management at home.133
Family/Home
Respond sensitively to family members with mental health conditions; know what community
resources exist; help family members make contact with appropriate services134; safely store
firearms.135,136
Clinical
Offer screening for depression in adults and adolescents (aged 12-18 years) when treatment
and follow-up services are available137,138; offer developmental screening of young children35; use
collaborative care for the management of depressive disorders139; deliver culturally competent care134;
develop crisis plans for persons with mental illness140; stay up-to-date on evidence-based clinical
preventive screening, counseling, and treatment guidelines.
Schools and Child Care
Implement evidenced-based mental health programs, staff members should be trained to identify
stress in children that leads to mental health problems, as well as signs of mental illness120,141;
implement evidence-based healthful living curricula in schools17,31; staff should know which community
resources exist, offer appropriate referrals, and act sensitively134; mental health professionals working
at schools should have specific training in child and adolescent mental health.141
Worksites
Employers should conduct assessments of office stress, health, and job satisfaction and use
interventions to target office stressors.142
Insurers Provide coverage for developmental screenings and psychosocial behavioral assessments for children
and adolescents with no cost sharing35; provide coverage for depression screening and intervention
services offered in primary care settings for adolescents and adults with no cost sharing34,rr; provide
coverage of mental health services in parity with other services.ss
Community
Services should take into account age, gender, race, and culture134; facilitate “portals to entry” to
services and treatment in the community134; publicize ways to access mental health crisis services
outside of emergency departments and create partnerships among emergency personnel, school,
community hospitals, law enforcement, and behavioral health crisis service providers to improve
coordination and communication140; support school-based and school-linked health services.31
Public Policies
Expand the availability of mental health services in outpatient and community settings134; provide
funding to support school-based and school-linked health services and achieve a statewide ratio of
1 school nurse for every 750 middle and high school students31; develop comprehensive systems
of care that include prevention, treatment, and recovery supports132,134; provide tax incentives to
encourage comprehensive worksite wellness programs17; implement a surveillance system to promote
developmental screenings143; provide funding for research on support and prevention strategies.134
qq State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. November 24, 2010.
rr Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
ss North Carolina Session Law 2007-268.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
21
HEALTHY NORTH CAROLINA 2020
ORAL HEALTH
2020 Objectives
An individual’s oral health plays a very
important role in their overall health.
Studies have shown direct links between
oral infections and other conditions, such
as diabetes, heart disease, stroke, and poor
pregnancy outcomes.144 Dental caries is the
most common chronic infectious disease
among children; if untreated, dental caries
can result in problems with speaking,
playing, learning, and receiving proper
nutrition.144,145 In addition, untreated oral
health problems in children and adults
can cause severe pain and suffering, and
those who delay care often have higher
treatment costs when they finally receive
it.146
OBJECTIVE 1: INCREASE THE PERCENTAGE OF CHILDREN
AGED 1-5 YEARS ENROLLED IN MEDICAID WHO RECEIVED
ANY DENTAL SERVICE DURING THE PREVIOUS 12 MONTHS
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Children of low-income families are more
likely to have tooth decay. One reason is that many children
with public coverage lack access to dental care.147 On average,
fewer than half of all North Carolinians aged 1-5 years enrolled in
Medicaid receive any dental care in a year.148
CURRENT (2008)148
2020 TARGET
46.9%
56.4%
OBJECTIVE 2: DECREASE THE AVERAGE NUMBER
OF DECAYED, MISSING, OR FILLED TEETH AMONG
KINDERGARTNERS
Rationale for selection: Dental decay in children can be measured
by the number of teeth affected by decay, the number of teeth
that have been extracted, or the number of teeth successfully
filled. The prevalence of decayed, missing, or filled teeth in
young children is higher in low-income populations and in rural
communities without fluoridated water.149
CURRENT (2008-09)tt
2020 TARGET
1.5
1.1
OBJECTIVE 3: DECREASE THE PERCENTAGE OF ADULTS
WHO HAVE HAD PERMANENT TEETH REMOVED DUE TO
TOOTH DECAY OR GUM DISEASE
Rationale for selection: Untreated tooth decay and gum disease
can lead to permanent tooth loss among adults. According to the
Centers for Disease Control and Prevention (CDC), nationally, one
in three adults has untreated tooth decay, and one in seven adults
has gum disease.150
CURRENT (2008)151
2020 TARGET
47.8%
38.4%
tt North Carolina Division of Public Health, North Carolina Department of Health and Human Services. Written (email) communication. April 28, 2010.
22
North Carolina Institute of Medicine
Disparities in Oral Health
Dental service among Medicaid-enrolled children: A higher percentage of Hispanic children enrolled in Medicaid receive
annual dental care than non-Hispanic white or non-Hispanic African American children. Among children aged 2-3
years, 59.3% of Hispanics receive such care versus 45.2% for non-Hispanic whites and 47.1% for non-Hispanic African
Americans (2007). Similarly, among children aged 4-6 years, 68.4% of Hispanics, 55.7% of non-Hispanic whites, and
56.4% of non-Hispanic African Americans receive annual dental care (2007).152 Generally, access to dental care is
more challenging for Medicaid recipients in the northeast and far western parts of the state because of the lack of
dentists and enrolled Medicaid providers in those areas.uu
Decayed, missing, or filled teeth among kindergartners: Although North Carolina-specific data are not yet available,
national data indicate that the greatest disparity in tooth decay is seen in non-Hispanic African American children
and Mexican American children aged 2-4 and 6-8 years.153
Adults with permanent teeth removed: Individuals with greater income and those with more years of education are more
likely to have had no teeth removed because of tooth decay or gum disease (2008). People with incomes of $15,000
or less are twice as likely to have had teeth removed than those with incomes of $75,000 or greater (2008). Similarly,
those with less than a high school education are twice as likely as those with a college education (2008). Older North
Carolinians are also more likely to have had permanent teeth removed (2008).151
Strategies to Improve Oral Health
Level of the
Socioecological Model
Strategies
Individual
Brush using fluoridated toothpaste and floss your teeth appropriately; visit the dentist regularly154;
avoid tobacco use.155
Family/Home
Promote good quality oral health155; help children to avoid frequent snacking between meals156; ensure
that children receive regular dental care from a pediatrician or dentist.157
Clinical
Apply dental sealants155; primary care clinicians should prescribe oral fluoride supplementation at
currently recommended doses to preschool children older than 6 months whose primary water source
is deficient in fluoride158; offer education to families or caregivers on prevention methods for dental
caries157; pediatricians should offer oral health risk assessments for patients beginning at 6 months if
the child does not have a regular dentist.143
Schools and Child Care
Establish school-based and school-linked dental sealant delivery programs159; offer referrals to
providers155; offer fluoride supplements in schools155; implement evidence-based healthful living
curricula in schools.17,31
Insurers Cover preventive and restorative care, including fluoride treatment, sealants, and oral surgery, if
necessary, for children157,vv; cover fluoride treatment for children with a fluoride-deficient water
source34,ww; cover oral health assessments starting at 6 months if the child does not have a dental
home.35
Community
Increase access to dental care for those most at risk for oral health problems155; support community
water flouridation160,161; support school-based and school-linked health services.31
Public Policies
Increase dental provider participation in the North Carolina Medicaid program149; increase the supply
of dentists in underserved areas and across North Carolina149,162; create policies that require community
water fluoridation160,161; encourage greater diversity in dental schools155; provide funding to support
school-based and school-linked health services and achieve a statewide ratio of 1 school nurse for
every 750 middle and high school students.31
uu Division of Medical Assistance, North Carolina Department of Health and Human Services. Written (email) communication. December 10, 2010.
vv The Patient Protection and Affordable Care Act requires the Secretary of the US Department of Health and Human Services to develop an essential health benefits
package which shall include oral health services for children. Patient Protection and Affordable Care Act, Pub L No. 111-148, §1302(b)(J).
ww Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
23
HEALTHY NORTH CAROLINA 2020
ENVIRONMENTAL HEALTH
2020 Objectives
The environment in which individuals
live and work affects their health.
Contaminants in water and air can have
adverse health consequences. Both shortterm and chronic exposure to pollution
can be serious health risks. Air pollution
from ozone can lead to respiratory
symptoms, disruption in lung function,
and inflammation of airways.163 Water
pollution has been linked to both acute
poisonings and chronic effects.164,165
The worksite is another aspect of the
environment that is important to consider
in the public’s health. Unsafe work
conditions can lead to poor health and
even to extreme outcomes such as death.
OBJECTIVE 1: INCREASE THE PERCENTAGE OF AIR
MONITOR SITES MEETING THE CURRENT OZONE STANDARD
OF 0.075 PPMxx
(KEY PERFORMANCE INDICATOR)
Rationale for selection: People with asthma are especially sensitive
to ozone exposure. Ozone has been linked to increased frequency
of asthma attacks and use of health care services. Ozone exposure
may also affect respiratory system development in very young
children.163
CURRENT (2007-09)yy
2020 TARGET
62.5%
100%
OBJECTIVE 2: INCREASE THE PERCENTAGE OF THE
POPULATION BEING SERVED BY COMMUNITY WATER
SYSTEMS (CWS) WITH NO MAXIMUM CONTAMINANT LEVEL
VIOLATIONS (AMONG PERSONS ON CWS)
Rationale for selection: A community water system is a type of
public water system that provides water to the same population
year-round.166 Approximately three out of four North Carolinians
reside in areas serviced by community water systems.167 Reducing
contaminants protects the public’s health by ensuring that those
on CWS receive safe drinking water.
CURRENT (2009)zz
2020 TARGET
92.2%
95.0%
OBJECTIVE 3: REDUCE THE MORTALITY RATE FROM
WORK-RELATED INJURIES (PER 100,000 EQUIVALENT
FULL-TIME WORKERS)
Rationale for selection: Although the actual number of North
Carolinians who die from work-related injuries is not large, these
deaths are unnecessary and preventable. Agriculture, forestry,
fishing, and hunting; construction; and transportation and utilities
are among the industries with the highest death rates in North
Carolina.aaa
xx
yy
zz
aaa
bbb
24
CURRENT (2008)bbb
2020 TARGET
3.9
3.5
Parts per million.
Division of Air Quality, North Carolina Department of Environment and Natural Resources. Written (email) communication. June 21, 2010.
Public Water Supply Section, North Carolina Department of Environment and Natural Resources. Written (email) communication. May 18, 2010.
Bureau of Labor Statistics, US Department of Labor. Written (email) communication. September 16, 2010.
Bureau of Labor Statistics, US Department of Labor. Written (email) communication. September 16, 2010.
North Carolina Institute of Medicine
Disparities in Environmental Health
Ozone: Urban and rural areas have ground-level ozone, although it tends to be higher in urban areas. In addition,
particular individuals are at increased risk from the deleterious effects of ozone exposure, including children, people
with asthma and lung disease, older adults, infants, and active people of all ages.168
Fatalities from work-related injuries: Certain industries are more hazardous and therefore have increased rates of
occupational fatality compared with rates of other industries. Compared with the overall 2008 state mortality rate
of 3.9 fatalities per 100,000 equivalent full-time workers, the rate is 41.7 fatalities (per 100,000 equivalent full-time
workers) for agriculture, forestry, fishing, and hunting; 10.2 fatalities (per 100,000 equivalent full-time workers)
for transportation and utilities; and 9.7 fatalities (per 100,000 equivalent full-time workers) for construction.ccc In
addition, national data show that certain groups are more at risk for fatal occupational injuries, including men,
individuals aged at least 65 years, and Hispanic workers.169,170
Strategies to Improve Environmental Health
Level of the
Socioecological Model
Strategies
Individual
Carpool, use public transportation, combine errands, conserve electricity, set your air conditioner to a
higher temperature171; properly use and dispose of hazardous materials like motor oil and pesticides
and use pesticides and fertilizers in moderation.172
Clinical
Work with community coalitions for strong state air pollution control measures173; advocate for
energy-saving and pollution-minimizing practices.173
Schools and Child Care
Encourage students to take part in the Youth at Work: Talking Safety occupational safety training
program174; enforce a “no idling” policy to improve air quality.175
Worksites
Reduce environmental risks in the workplace176; inform all employees of applicable safety and health
standards and protect all employees who work with hazardous materials177; meet Occupational Safety
and Health Act requirements to provide a workplace that is “free from recognized hazards that are
causing or are likely to cause death or serious physical harm.”ddd
Community
Establish carpools, public transportation, or bike-friendly community transportation systems171;
implement low-impact development requirements by zoning boards178; follow best available
technology for specific contaminants in community water systems, and refer to Environmental
Protection Agency (EPA) guidance for simultaneous compliance when making treatment changes179;
perform regular monitoring of the water supply as required by the Safe Drinking Water Act and the
North Carolina Drinking Water Act.eee,fff
Public Policies
Encourage implementation of fuel alternatives173; support policies that promote stronger emission
standards for vehicles180,181; support policies that promote reduction of power plant emissions182;
develop water rates that support future community water system infrastructure needs.183
ccc
ddd
eee
fff
Bureau of Labor Statistics, US Department of Labor. Written (email) communication. September 16, 2010.
29 USC §654.
42 USC §300g.
NCGS §130A-311.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
25
HEALTHY NORTH CAROLINA 2020
INFECTIOUS DISEASE AND FOODBORNE ILLNESS
2020 Objectives
The prevention of infectious diseases is
part of the historic bedrock of public
health practice. Fortunately, many
infectious diseases such as chicken pox,
measles, influenza, and hepatitis B can
now be prevented through immunizations.
However, people do not always receive the
recommended vaccinations and therefore
still become sick, become disabled, or die
from infectious diseases that are entirely
preventable. Foodborne illnesses are
among the most common of infectious
diseases. They can lead to acute illnesses,
hospitalizations, and even deaths.184
Foodborne illnesses are not vaccine
preventable but nonetheless are potentially
preventable through safe food preparation
and storage tactics.185
OBJECTIVE 1: INCREASE THE PERCENTAGE OF CHILDREN
AGED 19-35 MONTHS WHO RECEIVE THE RECOMMENDED
VACCINES
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Vaccines are described as one of the 10
great public health achievements of the 20th century.186 For every
dollar spent on the US childhood immunization program, 5 dollars
in direct costs and 11 dollars in additional costs to society are
saved.187
CURRENT (2007)188
2020 TARGET
77.3%
91.3%
OBJECTIVE 2: REDUCE THE PNEUMONIA AND INFLUENZA
MORTALITY RATE (PER 100,000 POPULATION)
Rationale for selection: In 2008, pneumonia and influenza yielded
the eighth leading cause of death among North Carolinians,
causing approximately 1,750 deaths.189 Individuals aged more than
65 years, those with chronic health conditions, pregnant women,
and young children are at higher risk of developing complications
such as pneumonia from the flu.190
CURRENT (2008)ggg
2020 TARGET
19.5
13.5
OBJECTIVE 3: DECREASE THE AVERAGE NUMBER OF
CRITICAL VIOLATIONS PER RESTAURANT/FOOD STANDhhh
Rationale for selection: Foodborne diseases cause about 47.8
million illnesses, 127,839 hospitalizations, and 3,037 deaths every
year in the United States.191 Improper holding temperatures,
poor personal hygiene of food handlers, unsafe food sources,
inadequate cooking, and contaminated equipment are the top
five food safety risk factors identified by the Centers for Disease
Control and Prevention (CDC).185 Critical violations are based upon
these identified risk factors.
CURRENT (2009)iii
2020 TARGET
6.1
5.5
ggg State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. May 13, 2010.
hhh As defined in 15A NCAC §18A.2601, a restaurant is a food service establishment which prepares or serves food and provides seating. A food stand is a food service
establishment, which prepares or serves foods, but does not provide seating for customers to use while eating or drinking.
iii Food Protection Branch, North Carolina Department of Environment and Natural Resources. Written (email) communication. September 29, 2010.
26
North Carolina Institute of Medicine
Disparities in Infectious Disease and Foodborne Illness
Vaccines among children aged 19-35 months: National data indicate that poverty is a contributing factor to disparities
seen in immunization rates. The immunization rate among children living below the poverty threshold is 75% versus
the national rate of 77.4% (for children receiving the 4:3:1:3:3:1 series in 2007).192
Pneumonia and influenza mortality: Pneumonia and influenza mortality most greatly affects individuals aged 65 years
or more. The mortality rate for this age group is 127.5 deaths per 100,000 population versus 9.0 deaths per 100,000
population in the 45- to 64-year-old age group and 1.2 deaths per 100,000 population in the 20- to 44-year-old age
group (2008).jjj
Strategies to Prevent and Reduce Infectious Disease and Foodborne Illness
Level of the
Socioecological Model
Strategies
Individual
Get the recommended immunizations193; wash your hands often.194,195
Family/Home
Make sure your children are immunized.193
Clinical
Offer patients age-appropriate immunizations and counsel them to receive age-appropriate
immunizations193,194,196; offer home visits for vaccination delivery; vaccinate health care workers against
influenza.197
Schools and Child Care
Offer vaccination programs in schools or organized child care centers that include education and
promotion, assessment and tracking of vaccination status, referral of school or child care attendees to
vaccination providers when needed, and provision of vaccines.198
Worksites
Offer worksite immunizations for influenza199; restaurants should reduce risk factors for food-borne
illness identified by the CDC and as outlined in North Carolina Administrative Code.200,kkk
Insurers Provide coverage with no cost sharing for all vaccinations recommended by the Advisory Committee
on Immunization Practices.193,lll
Community
Provide community interventions in combination to increase vaccine use among targeted
populations201; create programs to improve access to influenza vaccines for children aged 6 months to
18 years, individuals more than 50 years old, and those at high risk because of medical conditions.202
Public Policies
Fund outreach efforts to increase immunization rates for all recommended vaccines17; strengthen laws
and procedures to prevent foodborne illnesses, particularly in food service and retail establishments.203
jjj State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. November 24, 2010.
kkk 15A NCAC §18A.2601.
lll Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
27
HEALTHY NORTH CAROLINA 2020
SOCIAL DETERMINANTS OF HEALTH
2020 Objectives
Poverty, education level, and housing are
three important social determinants of
health. These three factors are strongly
correlated
with
individual
health.
People with higher incomes, more years
of education, and a healthy and safe
environment to live in have better health
outcomes and generally have longer life
expectancies. Although these factors
affect health independently, they also
have interactive effects on each other and
thus on health.17 For example, people in
poverty are more likely to engage in risky
health behaviors, and they are also less
likely to have affordable housing.204 In
turn, families with difficulties in paying
rent and utilities are more likely to report
barriers to accessing health care, higher
use of the emergency department, and
more hospitalizations.205
OBJECTIVE 1: DECREASE THE PERCENTAGE OF INDIVIDUALS
LIVING IN POVERTYmmm
(KEY PERFORMANCE INDICATOR)
Rationale for selection: In general, increasing income levels
correspond with gains in health and health outcomes–especially
at the lower end of the income scale. People in poverty have the
worst health, compared to people at higher income levels. For
example, compared with their counterparts, poor adults are more
likely to have chronic illnesses such as diabetes and heart disease,
and poor children are more likely to be in poor or fair health.206
CURRENT (2009)207
2020 TARGET
16.9%
12.5%
OBJECTIVE 2: INCREASE THE FOUR-YEAR HIGH SCHOOL
GRADUATION RATE
Rationale for selection: Adults who do not graduate from high
school are more likely to suffer from health conditions such as
heart disease, high blood pressure, stroke, high cholesterol, and
diabetes.17 Individuals with less education are also more likely
to engage in risky health behaviors, such as smoking and being
physically inactive.208
CURRENT (2008-09)209
2020 TARGET
71.8%
94.6%nnn
OBJECTIVE 3: DECREASE THE PERCENTAGE OF PEOPLE
SPENDING MORE THAN 30% OF THEIR INCOME ON RENTAL
HOUSING
Rationale for selection: Housing affordability is a problem that
affects mostly low-income individuals and families. People with
limited income may have problems paying for basic necessities,
such as food, heat, and medical needs.205 In addition, people with
limited incomes may be forced to live in substandard housing in an
unsafe environment.17
CURRENT (2008)210
2020 TARGET
41.8%
36.1%
mmmThis objective refers to individuals living in households with a total income below the Federal Poverty Threshold. For example, the official federal poverty guideline for
one person is $10,830 and for a family of four is $22,050 in 2010. http://aspe.hhs.gov/poverty/10poverty.shtml. Accessed January 4, 2010.
nnn The 2020 high school graduation target was set to correspond with targets set forth in North Carolina Session Law 2010-111 (Senate Bill 1246). The law directs the
State Board of Education to establish a model to improve the four-year high school graduation rate to 90% by 2018. The 2020 target is an extrapolation of the 2018
target.
28
North Carolina Institute of Medicine
Disparities in Social Determinants of Health
Poverty: Racial and ethnic minorities are more likely to live in poverty than non-Hispanic whites. Nationally, African
Americans and Hispanics experience the highest rates of poverty. Both groups are nearly three times as likely as nonHispanic whites to live in poverty.211 Higher levels of education are positively associated with higher incomes; thus,
people with less education are more likely to live in poverty.31
Four-year high school graduation: African Americans, Hispanics, and American Indians have the lowest four-year
graduation rates in the state at 63.2%, 59%, and 60%, respectively (2008-2009). Whites and Asian students have the
highest graduation rates in the state: 77.7% and 83.7%, respectively (2008-2009). In addition, the graduation rate
of economically disadvantaged students is 61.8%, a full 10 percentage points less than the overall state rate of 71.8%
(2008-2009).209
Strategies to Address Social Determinants of Health
Level of the
Socioecological Model
Strategies
Individual
Education, poverty: Finish high school and pursue higher education.206
Family/Home
Education, poverty: Encourage everyone in the family to get his or her high school diploma or GED
and to pursue higher education.206
Clinical
Education, poverty: Counsel parents and children about the importance of school and youth about
taking responsibility for school work.212
Schools and Child Care
Education: Expand the North Carolina Positive Behavior Support Initiative to include all schools in
order to reduce the number of short- and long-term suspensions and expulsions213; develop Learn and
Earn partnerships between community colleges and high schools214; support publicly funded, centerbased, comprehensive early childhood development programs for low-income children aged 3 to 5
years (eg More at Four and Smart Start)215; help low-wealth or underachieving districts meet state
proficiency standards31; expand alternative learning programs for students who have been suspended
from school that support continuous learning, behavior modifications, appropriate youth development,
and school success.31
Worksites
Poverty, housing: Provide outreach to employees regarding applying for the Earned Income Tax
Credit216; provide health insurance coverage.ooo
Community
Poverty: Conduct outreach to help people enroll in Supplemental Nutrition Assistance Programs
(SNAP).17
Education: Use proven school-community collaboration models to keep students in school.217
Housing: Create tenant-based rental assistance programs that offer vouchers or direct cash assistance
for low-income renters.218
Public Policies
Poverty: Increase the state Earned Income Tax Credit219,220; make the state’s child and dependent tax
credit refundable.221
Education: Raise the compulsory school attendance age222; pass policies and provide funding to
support the strategies listed in the schools and child care section above.
Housing: Increase funding to support affordable housing, such as the North Carolina Housing Trust
Fund.17
Poverty, housing: Support public policies that create new jobs223 and provide worker education and
training and work supports (eg child care)224; coordinate housing and transportation policies to reduce
transportation burdens to worksites and target job development in low- and moderate-income
neighborhoods.225 ooo Patient Protection and Affordable Care Act, Pub L No. 111-148, §1513.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
29
HEALTHY NORTH CAROLINA 2020
CHRONIC DISEASE
2020 Objectives
Chronic diseases such as heart disease,
cancer, and diabetes are major causes of
death and disability in North Carolina.17
Although genetics and other factors
contribute to the development of these
chronic health conditions, individual
behaviors play a major role. As much as
50% of individual health can be attributed
to behavior alone.226 Physical inactivity,
unhealthy eating, smoking, and excessive
alcohol consumption are four behavioral
risk factors underlying much of the burden
caused by chronic disease.227
OBJECTIVE 1: REDUCE THE CARDIOVASCULAR DISEASE
MORTALITY RATE (PER 100,000 POPULATION)
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Heart disease is the second leading cause
of death for men and women in North Carolina.228 The risk for
heart disease increases as a person ages. In addition to behavioral
risk factors, obesity, high blood pressure, high cholesterol, and
diabetes are other known risk factors for heart disease.229
CURRENT (2008)ppp
2020 TARGET
256.6
161.5
OBJECTIVE 2: DECREASE THE PERCENTAGE OF ADULTS
WITH DIABETES
Rationale for selection: The majority (90%-95%) of all people
diagnosed with diabetes have type 2 diabetes, formerly known as
non-insulin dependent or adult-onset diabetes. Diabetes can lead
to serious and costly health problems such as heart disease, stroke,
and kidney failure. Overweight/obesity and being older are risk
factors for diabetes.230
CURRENT (2009)231
2020 TARGET
9.6%
8.6%
OBJECTIVE 3: REDUCE THE COLORECTAL CANCER
MORTALITY RATE (PER 100,000 POPULATION)
Rationale for selection: Colorectal cancer is the third leading
cause of cancer death in both men and women in the country.
Screening can reduce the number of deaths because the disease
is very treatable if found early.232 However, one in three North
Carolinians (33.4%) aged 50 or more years report they have never
been screened (by sigmoidoscopy or colonoscopy) for colorectal
cancer.233
CURRENT (2008)qqq
2020 TARGET
15.7
10.1
ppp State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. July 9, 2010.
qqq State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. August 10, 2010.
30
North Carolina Institute of Medicine
Disparities in Chronic Disease
Cardiovascular disease (CVD) mortality: African Americans have the highest CVD mortality rate: 316.4 deaths per
100,000 population, compared with 237.9 deaths per 100,000 population for whites (2008). In addition, men
are more susceptible to CVD mortality than women, as indicated by rates of 303.7 and 209.5 deaths per 100,000
population, respectively (2008).rrr
Diabetes: African Americans are nearly twice as likely to have diabetes, compared with whites (15.6% versus 8.4%
in 2009). Compared with whites, American Indians are more likely to have diabetes (11.7% in 2009). In general,
individuals with less education and with lower incomes are also more likely to have diabetes (2009). Among individuals
with less than a high school education, 15.3% report diabetes, compared with 5.5% of college graduates (2009).
Of those with annual incomes less than $15,000, 14.6% report diabetes, compared with 4.9% of individuals with
incomes of $75,000 or greater (2009).234
Colorectal cancer mortality: The burden of death due to colorectal cancer is greatest among African Americans. The
mortality rate is 23.2 per 100,000 population for African Americans versus 14.0 per 100,000 population for whites
(2008). As expected, colorectal cancer death rates increase with age. The mortality rate jumps from 1.6 per 100,000
population for individuals aged 20-44 years to 19.3 per 100,000 population for individuals aged 45-64 years (2008).
The rate more than quadruples in the group aged 65 years or more (2008).sss
Strategies to Prevent and Reduce Chronic Disease
Level of the
Socioecological Model
Strategies
Individual
Eat more fruits and vegetables, increase physical activity level51; be tobacco free.26
Family/Home
Reduce screen time52; encourage eating healthy and physical activity51; maintain a tobacco-free home.27
Clinical
Screen for colorectal cancer (in adults beginning at age 50 years), type 2 diabetes in adults with high
blood pressure, cholesterol abnormalities; screen and offer intensive counseling and behavioral health
interventions for obese adults; offer dietary counseling for those at risk of cardiovascular disease or
other diet-related chronic diseases; prescribe aspirin for men and women aged 45-79 years to reduce
the number of heart attacks34; offer blood pressure management to individuals with diabetes235; offer
a follow-up colonoscopy within 15 months of diagnosis and treatment of an individual with colorectal
cancer236; prescribe beta-blockers for individuals with prior myocardial infarction.237
Schools and Child Care
Offer high-quality physical education and healthy foods and beverages17,51,53; implement evidencebased healthful living curricula in schools.17
Worksites
Offer worksite wellness programs intended to improve diet and amount of physical activity.238
Insurers With no cost sharing, cover colorectal cancer and diabetes screening as recommended by the
USPSTF; cover obesity screening for children aged more than 6 years and adults and for counseling
and behavioral interventions for those identified as obese; offer nutrition counseling for adults
with hyperlipidemia and other known risk factors for cardiovascular disease34,ttt; offer diabetes case
management by appointing a professional case manager who oversees and coordinates all of the
services received by someone with diabetes.239
Community
Offer diabetes self-management education programs240; implement Eat Smart, Move More
community-wide obesity prevention strategies17; promote menu labeling in restaurants53; build active
living communities53; support joint use of recreational facilities17; support school-based and schoollinked health services.31
Public Policies
Provide community grants to promote physical activity and healthy eating53; support community
efforts to build active living communities53; fund Eat Smart, Move More community-wide obesity
prevention plans17; provide funding to support school-based and school-linked health services and
achieve a statewide ratio of 1 school nurse for every 750 middle and high school students.31
rrr State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. November 24, 2010.
sss State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. November 24, 2010.
ttt Patient Protection and Affordable Care Act, Pub L No. 111-148, § § 1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
31
HEALTHY NORTH CAROLINA 2020
CROSS-CUTTING
2020 Objectives
These cross-cutting objectives represent
measures of population health in
North Carolina that span the other
focus areas. Average life expectancy
and self-reported health status offer a
proxy measure of the health of North
Carolina’s population. The percentage
of non-elderly uninsured individuals
provides an indication of the percentage
of people with improved access to health
care, including preventive services.
OBJECTIVE 1: INCREASE AVERAGE LIFE EXPECTANCY (YEARS)
(KEY PERFORMANCE INDICATOR)
Rationale for selection: Life expectancy is a summary measure for
population health because it summarizes mortality rates across all
age groups.241 North Carolina ranks 39th in the most recent national
rankings (2005) for average life expectancy.242
CURRENT (2008)uuu
2020 TARGET
77.5
79.5
OBJECTIVE 2: INCREASE THE PERCENTAGE OF ADULTS
REPORTING GOOD, VERY GOOD, OR EXCELLENT HEALTH
Rationale for selection: Self-reported health is often used as a measure
of overall population health.243 In 2009, North Carolina ranked 41st
among all states for this measure.244
CURRENT (2009)245
2020 TARGET
81.9%
90.1%
OBJECTIVE 3: REDUCE THE PERCENTAGE OF NON-ELDERLY
UNINSURED INDIVIDUALS (AGED LESS THAN 65 YEARS)
Rationale for selection: There are an estimated 1.7 million uninsured
individuals aged less than 65 years living in North Carolina.246 The
Patient Protection and Affordable Care Act (PPACA), passed by
Congress in April 2010, will extend affordable care to millions of
uninsured individuals across the country. However, each state is tasked
with implementation of the PPACA, which includes educating uninsured
individuals about insurance options available to them and helping them
to enroll. Increasing health insurance coverage will increase access to
care, including clinical preventive services.
CURRENT (2009)247
2020 TARGET
20.4%
8.0%
OBJECTIVE 4: INCREASE THE PERCENTAGE OF ADULTS WHO
ARE NEITHER OVERWEIGHT NOR OBESEvvv
Rationale for selection: Obesity increases an individual’s risk for a host
of chronic diseases, including heart disease, stroke, and certain cancers.
It also increases the risk for premature death. The CDC calls obesity
a “national health threat” and “a major public health challenge.”248
CURRENT (2009)249
2020 TARGET
34.6%
38.1%
uuu State Center for Health Statistics, North Carolina Department of Health and Human Services. Written (email) communication. July 9, 2010.
vvv The percentage of adults who are neither overweight nor obese equals 100% minus the total percentage of adults who are overweight or obese.
32
North Carolina Institute of Medicine
Disparities in the Cross-cutting Objectives
Life expectancy: Females have higher life expectancies than males (80 versus 74.5 years) (2000-2008). Whites have
higher life expectancies than African Americans (78.1 versus 73.8 years). Gender disparities persist between whites
and African Americans. The life expectancies is 80.7 years for white women versus 77.2 years for African American
women, and 75.5 years for white men versus 70.1 years for African American men (2000-2008).250 In addition,
certain subgroups of the population have life expectancies lower than the average. For example, the life expectancy of
people with serious mental illness is an average of 25 years less than that of the general population.251
Health status: Individuals with higher incomes or more education are more likely to report having good health. Among
individuals with annual incomes between $50,000 and $75,000, 91.8% report having good health, whereas only
54.5% with incomes less than $15,000 report having good health. More than 93% of people with college educations
report having good health, whereas only 61.6% of those without a high school diploma report having good health.
Also, African Americans and Hispanics are less likely than whites to report having good health.252
Uninsured: Individuals earning less than 138% of the federal poverty line (FPL) are more likely to be uninsured than
those earning more than 400% of the FPL (38.7% versus 6.0% in 2009). Between different age groups, the highest
uninsured rates are among individuals aged 19-29 years (36.0%), compared with those aged 45-54 years (17.4%).
More than 35% of individuals employed, part-time or full-time, by small firms (1 to 24 employees) were uninsured,
compared with only 10% of those employed by very large firms (more than 1,000 employees)(2009).253
Overweight/obesity among adults: Compared to women, men are more likely to be overweight or obese (70.7% versus
60.3% in 2009). In addition, African Americans and Hispanics are more likely to report being overweight or obese
than whites. Individuals with higher incomes or more education are also less likely to report being overweight or obese
(2009).254
Note about strategies to address cross-cutting objectives: All strategies listed in this publication affect life expectancy and/
or health status. Examples of strategies from other focus areas are included in this table. In addition, specific strategies
for increasing insurance coverage are provided. For additional strategies to address overweight/obesity among adults,
refer to the Physical Activity and Nutrition Focus Area’s strategy table on page 11.
Strategies to Address the Cross-cutting Objectives
Level of the
Socioecological Model
Strategies
Individual
Improve health status and life expectancy: Be tobacco free26; be substance abuse free17; eat healthy
and exercise regularly51; finish high school and pursue higher education.206
Increase health insurance coverage: Enroll in public or private health insurance coverage.www
Family/Home
Improve health status and life expectancy:Maintain a safe and tobacco-free home26; immunize
children255; promote good nutrition and an active lifestyle.51
Increase health insurance coverage: Enroll all family members in public or private health insurance
coverage; explore new options that may become available in 2014 with the implementation of The
Patient Protection and Affordable Care Act (PPACA).xxx
Clinical
Improve health status and life expectancy: Provide all screenings and services recommended by the US
Preventive Services Task Force (USPSTF) and provide all immunizations recommended by the Advisory
Committee on Immunization Practices (ACIP)256,257,yyy; provide all additional services recommended by
the Health Resources and Services Administration (HRSA) for children and women258,zzz; help educate
the public about health risks.
Increase health insurance coverage: Help uninsured patients enroll in public or private health
insurance.aaaa
www Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1103, 3510.
xxx Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1103, 3510.
yyy Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
zzz Patient Protection and Affordable Care Act, Pub L No. 111-148, §1001, enacting §2713(a)(3),(4) of the Public Health Service Act, 42 USC §300gg.
aaaa Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1103, 2202, 3510.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
33
HEALTHY NORTH CAROLINA 2020
CROSS-CUTTING
Strategies to Improve the Cross-cutting Objectives
Level of the
Socioecological Model
Schools and Child Care
Improve health status and life expectancy: Promote school and organized child care center-located
vaccination programs259; enforce tobacco-free policies30; offer high-quality physical education and
healthy foods and beverages17,51; implement evidence-based healthful living classes in schools17,31;
ensure that all students receive comprehensive sexuality education.17,100
Increase health insurance coverage: Identify uninsured students and assist with health insurance
enrollment.260
Worksites
Improve health status and life expectancy: Offer worksite wellness programs54; make worksites
tobacco free33; conduct assessments of office stress, health, and job satisfaction and use interventions to
target office stressors142; inform all employees of applicable safety and health standards and protect all
employees who work with hazardous materials.177
Increase health insurance coverage: Offer health insurance and help employees enroll in public and
private health insurance coverage.bbbb
Insurers Improve health status and life expectancy: Provide coverage with no cost sharing for all USPSTFrecommended preventive screening, counseling, and treatment, and for all ACIP-recommended
immunizations.34,cccc
Community
Improve health status and life expectancy: Implement Eat Smart, Move More community-wide
obesity prevention strategies17; build active living communities51; provide community interventions
in combination to increase vaccination among targeted populations201; expand smoking bans or
restrictions in community spaces36; support school-based and school-linked health services31; support
adoption of healthy, safe, accessible, affordable, and environmentally friendly homes63; reduce the
stigma related to mental illness134; fund expansion of family planning services and community-based
pregnancy prevention programs for low-income families, such as the Nurse Family Partnership17,85;
support community water fluoridation.160,161
Increase health insurance coverage: Actively promote new health insurance options made available
under the Patient Protection and Affordable Care Act; help individuals enroll in public and private
coverage.dddd
Public Policies
Improve health status and life expectancy: Increase tax on beer and wine17,124; enforce blood alcohol
content and “zero tolerance” laws for drunk driving126; fund injury surveillance and intervention17;
expand tobacco-free policies to all workplaces and in community establishments36; increase the
tobacco tax38; fund Eat Smart, Move More community obesity prevention plans17; build active
living communities51; require schools to offer high-quality physical education and healthy foods and
beverages17,51,53; require schools to implement evidence-based healthful living curricula in schools17,31;
pass policies that ensure comprehensive sexuality education for all students17,100; provide funding to
support school-based and school-linked health services and achieve a statewide ratio of 1 school nurse
for every 750 middle and high school students31; develop comprehensive systems of mental health care
that include prevention, treatment, and recovery supports.132,134
Increase health insurance coverage: Simplify the eligibility and enrollment process for public insurance
programs; conduct aggressive outreach to inform people about public and private insurance261; employ
patient navigators to help enroll people in public and private coverage.eeee
bbbb
cccc
dddd
eeee
34
Strategies
Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1103, 3510.
Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1001, 4105-4106, enacting §2713 of the Public Health Service Act, 42 USC §300gg.
Patient Protection and Affordable Care Act, Pub L No. 111-148, § §1103, 3510.
Patient Protection and Affordable Care Act, Pub L No. 111-148, §3510.
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
OBJECTIVES
Current
2020 Target
1. Decrease the percentage of adults who are current smokers
20.3% (2009)
13.0%
2. Decrease the percentage of high school students reporting current use of
any tobacco product
25.8% (2009)
15.0%
3. Decrease the percentage of people exposed to secondhand smoke in the
workplace in the past seven days
14.6% (2008)
0%
1. Increase the percentage of high school students who are neither
overweight nor obese
72.0% (2009)
79.2%
2. Increase the percentage of adults getting the recommended amount of
physical activity 46.4% (2009)
60.6%
3. Increase the percentage of adults who consume five or more servings of
fruits and vegetables per day
20.6% (2009)
29.3%
1. Reduce the unintentional poisoning mortality rate (per 100,000 population)
11.0 (2008)
9.9
2. Reduce the unintentional falls mortality rate (per 100,000 population)
8.1 (2008)
5.3
3. Reduce the homicide rate (per 100,000 population)
7.5 (2008)
6.7
1. Reduce the infant mortality racial disparity between whites and
African Americans
2.45 (2008)
1.92
2. Reduce the infant mortality rate (per 1,000 live births)
8.2 (2008)
6.3
3. Reduce the percentage of women who smoke during pregnancy
10.4% (2008)
6.8%
1. Decrease the percentage of pregnancies that are unintended
39.8% (2007)
30.9%
2. Reduce the percentage of positive results among individuals aged 15 to 24
tested for chlamydia
9.7% (2009)
8.7%
3. Reduce the rate of new HIV infection diagnoses (per 100,000 population)
24.7 (2008)
22.2
1. Reduce the percentage of high school students who had alcohol on one
or more of the past 30 days
35.0% (2009)
26.4%
2. Reduce the percentage of traffic crashes that are alcohol-related
5.7% (2008)
4.7%
3. Reduce the percentage of individuals aged 12 years and older reporting
any illicit drug use in the past 30 days
7.8% (2007-08)
6.6%
1. Reduce the suicide rate (per 100,000 population)
12.4 (2008) 8.3
2. Decrease the average number of poor mental health days among
adults in the past 30 days
3.4 (2008)
2.8
3. Reduce the rate of mental health-related visits to emergency departments
(per 10,000 population)
92.0 (2008)
82.8
Tobacco Use
Physical Activity and Nutrition
Injury and Violence
Maternal and Infant Health
Sexually Transmitted Disease and Unintended Pregnancy
Substance Abuse
Mental Health
HEALTHY NORTH CAROLINA 2020: A Better State of Health
35
HEALTHY NORTH CAROLINA 2020
OBJECTIVES
Current
2020 Target
1. Increase the percentage of children aged 1-5 years enrolled in Medicaid
who received any dental service during the previous 12 months
46.9% (2008)
56.4%
2. Decrease the average number of decayed, missing, or filled teeth among
kindergartners
1.5 (2008-09)
1.1
3. Decrease the percentage of adults who have had permanent teeth removed
due to tooth decay or gum disease
47.8% (2008)
38.4%
1. Increase the percentage of air monitor sites meeting the current ozone
standard of 0.075 ppm
62.5% (2007-09)
100.0%
2. Increase the percentage of the population being served by community
water systems (CWS) with no maximum contaminant level violations
(among persons on CWS)
92.2% (2009)
95.0%
3. Reduce the mortality rate from work-related injuries (per 100,000 equivalent
full-time workers)
3.9 (2008)
3.5
1. Increase the percentage of children aged 19-35 months who receive the
recommended vaccines
77.3% (2007)
91.3%
2. Reduce the pneumonia and influenza mortality rate (per 100,000
population)
19.5 (2008)
13.5
3. Decrease the average number of critical violations per restaurant/
food stand
6.1 (2009)
5.5
1. Decrease the percentage of individuals living in poverty
16.9% (2009) 12.5%
2. Increase the four-year high school graduation rate
71.8% (2008-09)
94.6%
3. Decrease the percentage of people spending more than 30% of their
income on rental housing
41.8% (2008)
36.1%
1. Reduce the cardiovascular disease mortality rate (per 100,000 population)
256.6 (2008)
161.5
2. Decrease the percentage of adults with diabetes
9.6% (2009)
8.6%
3. Reduce the colorectal cancer mortality rate (per 100,000 population)
15.7(2008)
10.1
1. Increase average life expectancy (years)
77.5 (2008)
79.5
2. Increase the percentage of adults reporting good, very good, or excellent
health
81.9% (2009)
90.1%
3. Reduce the percentage of non-elderly uninsured individuals (aged less
than 65 years) 20.4% (2009)
8.0%
4. Increase the percentage of adults who are neither overweight nor obese
34.6% (2009)
38.1%
36
North Carolina Institute of Medicine
Oral Health
Environmental Health
Infectious Disease and Foodborne Illness
Social Determinants of Health
Chronic Disease
Cross-cutting
HEALTHY NORTH CAROLINA 2020
ACKNOWLEDGMENTS
T
he Healthy NC 2020 project to develop the state’s 2020 objectives was generously supported by The Duke
Endowment, the Kate B. Reynolds Charitable Trust, and the North Carolina Health and Wellness Trust Fund.
Partners collaborating with the NCIOM on the Healthy NC 2020 project included the Governor’s Task Force for
Healthy Carolinians, the Division of Public Health, North Carolina Department of Health and Human Services (NC
DHHS); the Office of Healthy Carolinians, NC DHHS; and the State Center for Health Statistics, NC DHHS. All were
essential to accomplishing this work. The development of the 2020 objectives would not have been possible without
the guidance of the steering committee members, the contributions of the subcommittee members, and the expertise
of many other individuals.
We also extend appreciation to specific individuals for their expertise, advice, and continuous involvement in this
project, including Jeffrey Spade, FACHE, Executive Director, North Carolina Center for Rural Health Innovation and
Performance, Vice President, North Carolina Hospital Association, and Chair, Governor’s Task Force for Healthy
Carolinians; and to the following individuals within the Division of Public Health, North Carolina Department of
Health and Human Services (NC DHHS): Jeffrey P. Engel, MD, State Health Director; Ruth Petersen, MD, MPH,
Chronic Disease Section Chief; Lisa Harrison, MPH, Director, Office of Healthy Carolinians and Health Education;
Debi Nelson, MAEd, RHEd, Deputy Director, Office of Healthy Carolinians and Health Education; and Laura Edwards,
RN, MPA, Prevention Specialist. Appreciation also goes to Karen Knight, MS, Director, State Center for Health
Statistics, NC DHHS; Kathleen Jones-Vessey, MS, Manager, Statistical Services, State Center for Health Statistics,
NC DHHS; and Steven Cline, DDS, MPH, Assistant Secretary for Health Information Technology, NC DHHS, and
former Deputy State Health Director. In addition to the above groups and individuals, NCIOM staff made significant
contributions to the Healthy NC 2020 project. Pam Silberman, JD, DrPH, NCIOM President and CEO, and Mark
Holmes, PhD, past NCIOM Vice President, developed the framework for the development of the objectives. Jennifer
Hastings, MS, MPH, was the Healthy NC 2020 Project Director. Former NCIOM staff member Catherine Liao, MPH,
contributed significantly to this work. Paul Mandsager, an NCIOM intern, provided invaluable data and technical
support throughout this project. In addition, Berkeley Yorkery, MPP, NCIOM Project Director; Sharon Schiro, PhD,
NCIOM Vice President; Kimberly Alexander-Bratcher, MPH, NCIOM Project Director; and Rachel Williams, MPH,
NCIOM Research Assistant, made significant contributions, as did NCIOM interns Lauren Short and Lindsey Haynes.
HEALTHY NORTH CAROLINA 2020: A Better State of Health
37
HEALTHY NORTH CAROLINA 2020
GOVERNOR’S TASK FORCE FOR
HEALTHY CAROLINIANS
Jeffrey Spade, FACHE—Chair
Executive Director, North Carolina Center for Rural
Health Innovation and Performance; Vice President,
North Carolina Hospital Association
Lana T. Dial, MPH, MSPH
Court Improvement Program Manager, Court Programs
and Management Services Division, North Carolina
Administrative Office of the Courts
Betty Alexander, MPA, EdD
Chair, North Carolina Local Health Department
Accreditation Board; Member, North Carolina Minority
Health and Health Disparities Advisory Board; Retired
Professor, Clinical Laboratory Science, Director,
Gerontology Program, Winston-Salem State University
Jeffrey Engel, MD
State Health Director, Division of Public Health, North
Carolina Department of Health and Human Services
Commissioner Lee Kyle Allen
North Carolina Association of County Commissioners
Alice Ammerman, DrPH, RD
Director, Center for Health Promotion and Disease
Prevention; Professor, University of North Carolina at
Chapel Hill Gillings School of Global Public Health;
Designee for Dean Barbara Rimer, University of North
Carolina at Chapel Hill Gillings School of Global Public
Health
Battle Betts
Director of Policy, Planning and Finance, Albemarle
Regional Health Services
Bob Blackburn, EdD
President, Association of North Carolina Boards of
Health; Board of Directors, National Association of
Local Boards of Health; Vice Chair, North Carolina Local
Health Department Accreditation Board
Margaret Brake, MHA
Program Manager, Community Policy Management
Section, Division of Mental Health, Developmental
Disabilities and Substance Abuse Services, North
Carolina Department of Health and Human Services
Missy Brayboy, BS
Director, Youth Tobacco Prevention and American
Indian Health Initiative, North Carolina Commission of
Indian Affairs
Paula Hudson Collins
Chief Health and Community Relations Officer,
Office of the State Superintendent, Department of
Public Instruction; Designee for June Atkinson, State
Superintendent, Department of Public Instruction
38
Clay “Randy” Foreman III
Senator James Forrester, MD
North Carolina Senate
Beverly Foster, PhD, MPH, MN, RN
Clinical Associate Professor and Director, Undergraduate
Program, University of North Carolina at Chapel Hill
School of Nursing; North Carolina Nurses Association;
Chair, Foundation for Nursing Excellence
Judy Fourie
President, Fourie Insurance; Member, North Carolina
Chamber of Commerce
Merle Green, MPH
Health Director, Guilford County Department of Public
Health; North Carolina Association of Local Health
Directors
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education
Jennifer Hastings, MS, MPH
Project Director, North Carolina Institute of Medicine
Mercedes Hernández-Pelletier, MPH, CHES
Health Educator, HACE, Medical Evaluation and Risk
Assessment Unit, Occupational and Environmental
Epidemiology Branch, Division of Public Health, North
Carolina Department of Health and Human Services
Patricia Shannon Hopson, DO
Endocrinologist, Caromont Endocrinology Associates;
Member, North Carolina Medical Society
Representative Verla Insko
North Carolina House of Representatives
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
GOVERNOR’S TASK FORCE FOR
HEALTHY CAROLINIANS
Cynthia Marion
Child Nutrition Director, Stokes County; Designee
for Commissioner Steve Troxler, North Carolina
Department of Agriculture and Consumer Services
Kathy McGaha
Program Director, Healthy Carolinians of Macon
County
Barbara A. Moeykens, MS
Social Marketing and Communications Director, North
Carolina Health and Wellness Trust Fund
Senator William R. Purcell
North Carolina Senate
Andrea D. Radford, DrPH, MHA
Research Fellow, North Carolina Rural Health Research
and Policy Analysis Center; Designee for John Price,
Director, Office of Rural Health and Community Health,
North Carolina Department of Health and Human
Services
Meg Molloy, DrPH, MPH, RD
President and CEO, NC Prevention Partners
M. La Verne Reid, PhD, MPH
Associate Dean, College of Behavioral and Social
Sciences; Professor, Department of Public Health
Education; Principal Investigator, Health Disparities
Initiative, North Carolina Central University
Thea Monet, MAEd
Executive Director, My Doc Cares Program, Old North
State Medical Society
Susan J. Richardson
Senior Program Officer, Kate B. Reynolds Charitable
Trust
James R. Morrison, MPH
President, United Way of North Carolina
Vera Robinson
Ron Morrow, EdD
Executive Director, North Carolina Alliance for
Athletics, Health, Physical Education, Recreation, and
Dance
Rosa Navarro, MS
Director of Training and Technical Assistance, North
Carolina Community Health Center Association
Lloyd Novick, MD, MPH
Chair, Department of Public Health, East Carolina
University Brody School of Medicine
Representative Diane Parfitt
North Carolina House of Representatives
M. Alec Parker, DMD
Executive Director, North Carolina Dental Society
Barbara Pullen-Smith, MPH
Director, Office of Minority Health and Health
Disparities, Division of Public Health, North Carolina
Department of Health and Human Services
HEALTHY NORTH CAROLINA 2020: A Better State of Health
John Carson Rounds, MD
North Carolina Academy of Family Physicians
Pam Seamans, MPP
Executive Director/Policy Director, North Carolina
Alliance for Health
Maria Spaulding
Deputy Secretary, Long-Term Care and Services, North
Carolina Department of Health and Human Services;
Designee for Lanier Cansler, Secretary, North Carolina
Department of Health and Human Services
Lynette Rivenbark Tolson
Executive Director, North Carolina Association of
Local Health Directors, North Carolina Public Health
Association
Thad B. Wester, MD
Emeritus Member for Life
39
HEALTHY NORTH CAROLINA 2020
STEERING COMMITTEE MEMBERS
Battle Betts
Director of Policy, Planning and Finance, Albemarle
Regional Health Services; Member, Governor’s Task
Force for Healthy Carolinians
Dorothy Cilenti, DrPH, MPH, MSW
Deputy Director, North Carolina Institute for Public
Health, Clinical Assistant Professor, Department
of Maternal and Child Health, University of North
Carolina at Chapel Hill Gillings School of Global Public
Health
Steve Cline, DDS, MPH
Assistant Secretary, Health Information Technology,
North Carolina Department of Health and Human
Services, former Deputy State Health Director
John Dervin
Policy Advisor, Office of the Governor
Roddy Drake, MD
Health Director, Granville-Vance District Health
Department
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Jeffrey P. Engel, MD
State Health Director, Division of Public Health, North
Carolina Department of Health and Human Services;
Member, Governor’s Task Force for Healthy Carolinians
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Kathleen Jones-Vessey, MS
Manager, Statistical Services, State Center for Health
Statistics, North Carolina Department of Health and
Human Services
Elizabeth Walker Kasper, MSPH
Research Assistant, America’s Health Rankings Scientific
Advisory Committee, Cecil G. Sheps Center for Health
Services Research
40
Karen L. Knight, MS
Director, State Center for Health Statistics, North
Carolina Department of Health and Human Services
Meg Molloy, DrPH, MPH, RD
President and CEO, NC Prevention Partners; Member,
Governor’s Task Force for Healthy Carolinians
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Ruth Petersen, MD, MPH
Chief, Chronic Disease and Injury Section, Division of
Public Health, North Carolina Department of Health
and Human Services
Barbara Pullen-Smith, MPH
Director, Office of Minority Health and Health
Disparities, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Terri Qadura
Planner-Evaluator, Division of Mental Health,
Developmental Disabilities and Substance Abuse
Services, North Carolina Department of Health and
Human Services
Tom Ricketts, PhD, MPH
Deputy Director, Cecil G. Sheps Center for Health
Services Research; Professor, University of North
Carolina at Chapel Hill Gillings School of Global
Public Health; Member, Scientific Advisory Committee,
America’s Health Rankings
Jeff Spade, FACHE
Executive Director, North Carolina Center for Rural
Health Innovation and Performance; Vice President,
North Carolina Hospital Association; Chair, Governor’s
Task Force for Healthy Carolinians
Lynette Rivenbark Tolson
Executive Director, North Carolina Association of
Local Health Directors, North Carolina Public Health
Association; Member, Governor’s Task Force for Healthy
Carolinians
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Tobacco Use Subcommittee
Molly Aldridge, MPH
Epidemiologist, Tobacco Prevention and Control Branch,
Division of Public Health, North Carolina Department
of Health and Human Services
Deborah Bailey, PhD
Director, Academic Community Service Learning
Program, North Carolina Central University
Margaret Brake, MHA
Program Manager, Prevention and Early Intervention
Team, Community Policy Management Section, Division
of Mental Health, Developmental Disabilities and
Substance Abuse Services, North Carolina Department
of Health and Human Services; Member, Governor’s
Task Force for Healthy Carolinians
Tom Brown
Program Officer, Tobacco Initiatives, NC Health and
Wellness Trust Fund
James Cassell, MA
Head of Survey Operations, NC Behavioral Risk Factor
Surveillance System Coordinator, State Center for Health
Statistics, North Carolina Department of Health and
Human Services
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Megan Hauser, MA
Youth Tobacco Prevention Specialist,
Martin-Tyrrell-Washington District Health Department
Sally Herndon, MPH
Head, Tobacco Prevention and Control Branch, Division
of Public Health, North Carolina Department of Health
and Human Services
HEALTHY NORTH CAROLINA 2020: A Better State of Health
Roxanne Leopper, MS
Policy Director, FirstHealth of the Carolinas, Moore
County Healthy Carolinians
Jim Martin, MS
Director of Policy and Programs, Tobacco Prevention
and Control Branch, Division of Public Health, North
Carolina Department of Health and Human Services
Nidu Menon, PhD
Director of Evaluation, North Carolina Health and
Wellness Trust Fund
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Peg O’Connell, JD
Senior Advisor, Government and Legislative Affairs,
Fuquay Solutions, Inc.; Tobacco Prevention Policy
Committee Chair, NC Alliance for Health
Mike Placona
Evaluation Specialist, Tobacco Prevention and Control
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
Leah Ranney, PhD
Associate Director, Tobacco Prevention and Evaluation
Program, University of North Carolina at Chapel Hill
School of Medicine
Pamela Seamans, MPP
Executive Director/Policy Director, North Carolina
Alliance for Health; Member, Governor’s Task Force for
Healthy Carolinians
Jeff Spade, FACHE
Executive Director, North Carolina Center for Rural
Health Innovation and Performance; Vice President,
North Carolina Hospital Association; Chair, Governor’s
Task Force for Healthy Carolinians
Betsy Vetter
North Carolina Director of Government Relations,
American Heart Association Mid-Atlantic Affiliate
41
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Physical Activity and Nutrition Subcommittee
Jenni Albright, MPH
Manager of Evaluation and Surveillance, Physical
Activity and Nutrition Branch, Division of Public
Health, North Carolina Department of Health and
Human Services
Ron Morrow, EdD
Executive Director, North Carolina Alliance for
Athletics, Health, Physical Education, Recreation, and
Dance; Member, Governor’s Task Force for Healthy
Carolinians
Alice Ammerman, DrPH, RD
Director, Center for Health Promotion and Disease
Prevention, Professor, Department of Nutrition,
University of North Carolina at Chapel Hill Gillings
School of Global Public Health Medicine; Member,
Governor’s Task Force for Healthy Carolinians
Donna Miles, PhD
CHAMP Survey Coordinator, State Center for Health
Statistics, North Carolina Department of Health and
Human Services
Diane Beth, MS, RD, LDN
Nutrition Manager, Physical Activity and Nutrition
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
Philip Bors, MPH
Project Officer, Active Living By Design, North Carolina
Institute of Public Health, University of North Carolina
at Chapel Hill Gillings School of Global Public Health
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Suzanne Havala Hobbs, DrPH, MS, RD, FADA
Clinical Associate Professor, Director, Doctoral Program
in Health Leadership, Department of Health Policy and
Management, Department of Nutrition, University of
North Carolina at Chapel Hill Gillings School of Global
Public Health
42
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Lori Schneider, MA, CHES, PAPHS
Physical Activity Specialist, Physical Activity and
Nutrition Branch, Division of Public Health, North
Carolina Department of Health and Human Services
Pamela Seamans, MPP
Executive Director/Policy Director, North Carolina
Alliance for Health; Member, Governor’s Task Force for
Healthy Carolinians
Jackie Sergent, MPH, RD, LDN
Health Promotion Coordinator, Granville-Vance District
Health Department
Doug Urland, MPA
Health Director, Catawba County Health Department
Betsy Vetter
North Carolina Director of Government Relations,
American Heart Association Mid-Atlantic Affiliate
Alexander White, JD, MPH
Policy Intervention Specialist, Heart Disease and Stroke
Prevention Branch, Division of Public Health, North
Carolina Department of Health and Human Services
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Injury and Violence Subcommittee
Thomas D. Bridges
Health Director, Henderson County Department of
Public Health
Chris Bryant, MEd
Primary Prevention Specialist, Diabetes Prevention and
Control Branch, Chronic Disease and Injury Section,
Division of Public Health, North Carolina Department
of Health and Human Services
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Scott Proescholdbell, MPH
Epidemiologist, Injury and Violence Prevention Branch,
Division of Public Health, North Carolina Department
of Health and Human Services
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Kelly M. Ransdell, MA
Deputy Director, Office of State Fire Marshal, Director,
Safe Kids NC, North Carolina Department of Insurance
Marsha Ford, MD
Director, Carolinas Poison Center
Sharon Rhyne, MHA, MBA
Health Promotion Manager, Chronic Disease and Injury
Section, Division of Public Health, North Carolina
Department of Health and Human Services
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Linda Hughes
Health Education Specialist, Robeson County Health
Department
Brittany Melvin
Public Health Educator, Robeson County Health
Department
Carol Runyan, PhD, MPH
Director, Injury Prevention Research Center; Professor,
Department of Health Behavior and Health Education;
Professor, Pediatrics, University of North Carolina at
Chapel Hill
Janice White, MEd, SLP
TBI Program Coordinator, Division of Mental Health,
Developmental Disabilities and Substance Abuse
Services, North Carolina Department of Health and
Human Services
Maternal and Infant Health Subcommittee
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Janice Freedman, MPH
Executive Director, North Carolina Healthy Start
Foundation
Lisa Harrison
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
HEALTHY NORTH CAROLINA 2020: A Better State of Health
Joe Holliday, MD, MPH
Women’s Health Branch Head, Women’s and Children’s
Health Section, Division of Public Health, North
Carolina Department of Health and Human Services
Sarah McCracken Cobb
MPH, SSDI Project Coordinator, Women’s and
Children’s Health Section, Division of Public Health,
North Carolina Department of Health and Human
Services
Carolyn Moser, RN, MPA
Health Director, Madison County Health Department
43
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Maternal and Infant Health Subcommittee continued
Laura Mrosla, MPH, MSW
Health Educator, Guilford County Health Department
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Belinda Pettiford, MPH
Perinatal Health and Family Support Unit Supervisor,
Women’s Health Branch, Women’s and Children’s
Health Section, Division of Public Health, North
Carolina Department of Health and Human Services
Susan Robinson, MEd
Mental Health Program Manager/Planner, Prevention
and Early Intervention, Community Policy Management,
Division of Mental Health, Developmental Disabilities
and Substance Abuse Services, North Carolina
Department of Health and Human Services
Starleen Scott-Robbins, MSW, LCSW
Best Practice Consultant, Women’s Treatment
Coordinator, Division of Mental Health, Developmental
Disabilities and Substance Abuse Services, North
Carolina Department of Health and Human Services
Sarah Verbiest, DrPH, MSW, MPH
Executive Director, UNC Center for Maternal and Infant
Health
Sexually Transmitted Disease and Unintended
Pregnancy Subcommittee
Jacquelyn Clymore, MS
State AIDS/STD Director, Communicable Diseases
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
Cathy Kenzig
Executive Director, Alliance for Children and Youth;
Gaston County Healthy Carolinians
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Alvina Long Valentin, RN, MPH
Women’s Health Network Supervisor, Women’s Health
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Bernie Operario
Public Health Program Consultant, Family Planning and
Reproductive Health Unit, Division of Public Health,
North Carolina Department of Health and Human
Services
Joe Holliday, MD, MPH
Women’s Health Branch Head, Women’s and Children’s
Health Section, Division of Public Health, North
Carolina Department of Health and Human Services
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Bill Jones, MPH
Epidemiologist II, Communicable Disease Branch,
Division of Public Health, North Carolina Department
of Health and Human Services
Bill Smith, MPH
Health Director, Robeson County Health Department
44
Guoben Zhao, PhD
Public Health Epidemiologist I, Communicable Disease
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Substance Abuse Subcommittee
Matt Avery
Supervisor, Vital Statistics, State Center for Health
Statistics, North Carolina Department of Health and
Human Services
Kathleen Jones-Vessey, MS
Manager, Statistical Services, State Center for Health
Statistics, North Carolina Department of Health and
Human Services
Sheila Davies, MPA
Community Development Specialist, Dare County
Health Department
Joseph Martinez, JD
Executive Director, FIRST at Blue Ridge
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Michael Eisen, MA, LPC
State Administrator, NC Preventing Underage Drinking
Initiative/Enforcing Underage Drinking Laws Program,
Division of Mental Health, Developmental Disabilities
and Substance Abuse Services, North Carolina
Department of Health and Human Services
Maria Fernandez, PhD
Planner-Evaluator/QM Consultant, Community Policy
Management Section, Division of Mental Health,
Developmental Disabilities and Substance Abuse
Services, North Carolina Department of Health and
Human Services
Anne Hardison, MEd
Coordinator, Coastal Coalition for Substance Abuse
Prevention
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Tanya Paul
Intern, Coastal Coalition for Substance Abuse
Prevention; Graduate Student, East Carolina University
Janice Petersen, PhD
Director, Office of Prevention; Team Leader, Prevention
and Early Intervention, Division of Mental Health,
Developmental Disabilities and Substance Abuse
Services, North Carolina Department of Health and
Human Services
Tanya Roberts
Media Coordinator, Coastal Coalition for Substance
Abuse Prevention
Flo Stein, MPH
Chief, Community Policy Management, Division
of Mental Health, Developmental Disabilities and
Substance Abuse Services, North Carolina Department
of Health and Human Services
Anne Thomas, RN, BSN, MPA
Health Director, Dare County Health Department
Mental Health Subcommittee
Marisa E. Domino, PhD
Associate Professor, Department of Health Policy and
Management, University of North Carolina at Chapel
HIll Gillings School of Global Public Health
Alan R. Ellis, MSW
Research Associate and Fellow, Cecil G. Sheps Center for
Health Services Research
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
HEALTHY NORTH CAROLINA 2020: A Better State of Health
45
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Mental Health Subcommittee continued
Maria Fernandez, PhD
Planner-Evaluator/QM Consultant, Community Policy
Management Section, Division of Mental Health,
Developmental Disabilities and Substance Abuse
Services, North Carolina Department of Health and
Human Services
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Susan Robinson, MEd
Mental Health Program Manager/Planner, Prevention
and Early Intervention, Community Policy Management,
Division of Mental Health, Developmental Disabilities
and Substance Abuse Services, North Carolina
Department of Health and Human Services
Anne Marie Lester, MS, LPC
Executive Director, Polk Wellness Center
Joel Rosch, PhD
Senior Research Scholar, Center for Child and Family
Policy, Duke University
Kathy McGaha
Project Director, Healthy Carolinians of Macon County;
Member, Governor’s Task Force for Healthy Carolinians
Dorothee Schmid, MA
Statistician, State Center for Health Statistics, North
Carolina Department of Health and Human Services
Joseph P. Morrissey, PhD
Professor of Health Policy and Management, University
of North Carolina at Chapel Hill Gillings School of
Global Public Health, School of Medicine, Cecil G.
Sheps Center for Health Services Research
Chris Szwagiel, DrPH, MPH, MS
Director, Franklin County Health Department
John Tote
QMHP President, Tote Leadership Solutions, LLC
Oral Health Subcommittee
Deana Billings
Wilkes Public Health Dental Clinic
Mark Casey, DDS, MPH
Dental Director, Division of Medical Assistance, North
Carolina Department of Health and Human Services
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Anna Hamby
Coordinator, Healthy Yadkin
Scott Harrelson, MPA
Craven County Health Director, Craven County Health
Department
46
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Harry Herrick, MSPH, MSW
Behavioral Risk Factor Surveillance System Analyst, State
Center for Health Statistics, North Carolina Department
of Health and Human Services
James Hupp, DMD, MD, JD
Dean and Professor of Oral-Maxillofacial Surgery,
School of Dental Medicine, East Carolina University
Rebecca S. King, DDS, MPH
Section Chief, Public Health State Dental Director, Oral
Health Section, and Director, Dental Public Health and
Residency Training Program, Division of Public Health,
North Carolina Department of Health and Human
Services
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Oral Health Subcommittee continued
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Gary Rozier, DDS
Professor, Health Policy and Management, University of
North Carolina at Chapel Hill Gillings School of Global
Public Health
M. Alec Parker, DMD
Executive Director, North Carolina Dental Society;
Member, Governor’s Task Force for Healthy Carolinians
Amanda Stamper, CHES, RHEd
Health Education Specialist, Wilkes County Health
Department/Healthy Carolinians
Environmental Risks Subcommittee
Laura Boothe
Attainment Planning Branch Supervisor, Division of
Air Quality, Department of Environment and Natural
Resources
George Bridgers, CPM
Meteorologist II, Division of Air Quality Planning
Section, Attainment Planning Branch, North Carolina
Department of Environment and Natural Resources
Doug Campbell, MD, MPH
Branch Head, Occupational and Environmental
Epidemiology Branch, Division of Public Health, North
Carolina Department of Health and Human Services
Julia Cavalier, PE
Capacity Development Team Leader, Public Water Supply
Section, North Carolina Department of Environment
and Natural Resources
Holly Coleman, MS, RS
Health Director, Chatham County Public Health
Department
Traci Colley, RS
Program Specialist, Children’s Environmental Health
Section, Union County Health Department
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
HEALTHY NORTH CAROLINA 2020: A Better State of Health
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
Sheila A. Higgins, RN, MPH, COHN-S
Manager, Occupational Surveillance Unit, Occupational
and Environmental Epidemiology Branch, Division of
Public Health, North Carolina Department of Health
and Human Services
Evan O. Kane, PG
Groundwater Planning Supervisor, Division of Water
Quality, North CarolinaDepartment of Environment
and Natural Resources
Jackie Morgan
Health Promotions Supervisor, Union County Health
Department
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
Edward Norman, MPH
Environmental Supervisor, North Carolina Department
of Environment and Natural Resources
Kathy Shea, MD, MPH
Adjunct Professor, Maternal and Child Health,
University of North Carolina at Chapel Hill Gillings
School of Global Public Health
47
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Environmental Risks Subcommittee continued
Mina Shehee, PhD
Supervisor, Medical Evaluation and Risk Assessment
Unit, Occupational and Environmental Epidemiology
Branch, Division of Public Health, North Carolina
Department of Health and Human Services
Jeff Spade, FACHE
Executive Director, North Carolina Center for Rural
Health Innovation and Performance; Vice President,
North Carolina Hospital Association; Chair, Governor’s
Task Force for Healthy Carolinians
Lisa Spry, BS
Public Health Education Specialist, Albemarle Regional
Health Services
Chris Szwagiel, DrPH, MPH, MS
Director, Franklin County Health Department
Matt Womble, MHA, EMT-P
Rural Hospital Specialist, Office of Rural Health and
Community Care, North Carolina Department of
Health and Human Services
Infectious Disease and Foodborne Illness Subcommittee
Linda Charping, MEd, RHEd
Health Education Director, Henderson County
Department of Public Health
Megan Davies, MD
State Epidemiologist and Section Chief, Epidemiology
Section, Division of Public Health, North Carolina
Department of Health and Human Services
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Amy Grimshaw Guerriero, MS, MSW
Data Analyst, Immunization Branch, Division of Public
Health, North Carolina Department of Health and
Human Services
Laura Guderian, MD
Preventive Medicine Resident, UNC Preventive Medicine,
UNC Hospitals
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
48
Pamela R. Jenkins, EdD, MSN, CNS, RN
Consultant, Foundation for Nursing Excellence and
Embry-Riddle Aeronautical University; Adjutant Faculty,
University of North Carolina at Chapel Hill School of
Nursing and Gillings School Global Public Health
Jean-Marie Maillard, MD, MSc
Medical Director, Communicable Disease Branch,
Epidemiology Section, Division of Public Health, North
Carolina Department of Health and Human Services
Larry D. Michael, REHS, MPH
Branch Head, Food Protection Branch, Division of
Environmental Health, North Carolina Department of
Environment and Natural Resources
Zack Moore, MD, MPH
Epidemiologist, Epidemiology Section, Division of Public
Health, North Carolina Department of Health and
Human Services
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
David Sweat, MPH
Food-Borne Disease Epidemiologist, Communicable
Disease Branch, Division of Public Health, North
Carolina Department of Health and Human Services
North Carolina Institute of Medicine
HEALTHY NORTH CAROLINA 2020
SUBCOMMITTEE MEMBERS
Social Determinants of Health Subcommittee
Betty Alexander, MPA, EdD
Chair, North Carolina Local Health Department
Accreditation Board; Member, North Carolina Minority
Health and Health Disparities Advisory Board; Retired
Professor, Clinical Laboratory Science, Director,
Gerontology Program, Winston-Salem State University;
Member, Governor’s Task Force for Healthy Carolinians
Missy Brayboy, BS
Director, Youth Tobacco Prevention and American
Indian Health Initiative, North Carolina Commission
of Indian Affairs; Member, Governor’s Task Force for
Healthy Carolinians
Annette DuBard, MD, MPH
Director of Informatics, Quality, and Evaluation, North
Carolina Community Care Networks, Inc.
Laura Edwards, RN, MPA
Prevention Specialist, Division of Public Health, North
Carolina Department of Health and Human Services
Jessica Gavett, MBA
Community Health Services, FirstHealth of the
Carolinas
Lisa Harrison, MPH
Director, Office of Healthy Carolinians and Health
Education, Division of Public Health, North Carolina
Department of Health and Human Services; Member,
Governor’s Task Force for Healthy Carolinians
George Hill
Senior Public Health Program Consultant, Office of
Minority Health and Health Disparities, North Carolina
Department of Health and Human Services
Rebekah D. King
Policy and Program Analyst, North Carolina Housing
Finance Agency
Debbie Mason, MPH, CHES
Health Policy Unit Supervisor, Forsyth County Infant
Mortality Reduction Coalition, Forsyth County
Department of Public Health
HEALTHY NORTH CAROLINA 2020: A Better State of Health
Lynne M. Mitchell, MS, RD, LDN
Preventive Health Services Director, Forsyth County
Department of Public Health
Debi Nelson, MAEd, RHEd
Deputy Director, Office of Healthy Carolinians and
Health Education, Division of Public Health, North
Carolina Department of Health and Human Services
J. Nelson-Weaver
Health Partners, Buncombe County Healthy
Carolinians, Buncombe County Department of Health
Tammy Norville
Primary Care Systems Specialist, PCO Coordinator,
Office of Rural Health and Community Care, North
Carolina Department of Health and Human Services
Lloyd Novick, MD, MPH
Chair, Department of Public Health, East Carolina
University Brody School of Medicine; Member,
Governor’s Task Force for Healthy Carolinians
Meka Sales, MS, CHES
Program Officer, The Duke Endowment
Willard Tanner, MA
formerly of the Forsyth County Department of Public
Health, Forsyth County Healthy Carolinians
Louisa Warren
Senior Policy Advocate, North Carolina Justice Center
Alexander White, JD, MPH
Policy Intervention Specialist, Heart Disease and Stroke
Prevention Branch, Division of Public Health, North
Carolina Department of Health and Human Services
Debora Williams
Graduation Initiatives, North Carolina Department of
Public Instruction
Matt Womble, MHA, EMT-P
Rural Hospital Specialist, Office of Rural Health and
Community Care, North Carolina Department of
Health and Human Services
49
HEALTHY NORTH CAROLINA 2020
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